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Quality Assurance In Breast CancerScreening Mammography
Dr. Egle Jonaitiene, Dr. Laima Grinyte
2016 09 19-23
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Enviroment of screening mammography
• The colour, size and placement of the mammography machine
• The room designated for breast imaging only.
• The temperature and the lighting in the X-ray room
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Radiographer. Introduction to the examination
• Creation of personal relationship with the woman.
• Determination the woman’s previous mammographic experience and past breast problems.
• Record of any current breast symptoms or information, which may be of importance to the radiologist, particularly on the underside of the breast
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Information to the radiologist
Scars
Skin formations
Palpable lumps
Niple retraction
K
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Information to the woman
• The number of views to be taken and an outline of thepositioning
• Explanation of the importance of compression
• The procedure for notifying the results
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Starting the examination
• Select size of breast support table and compression paddle
• Clean the support table and compression paddle
• Select chamber position
• Place cassette in cassette holder
• Ensure correct identifications of the woman are in place
• Position the breast
• Remove any overlying artefacts e.g. spectacles, shoulders and skin folds
• Apply the compression slowly and carefully until the breast is firmly held
• Make the exposure
• Release the compression immediately
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Size of breast support table and compression paddle.Chamber position.
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Positioning
• Breast positioning is an art.
• Incorrect positioning is the most common problem.
• Skills required to perform optimal mammographic positioning are high.
• Sufficient time to carry out the investigation order to produce optimal images.
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Positioning. CC view• The medial border of the breast is
shown
• As much as possible of the lateral aspect of the breast is shown
• If possible, the pectoral muscle shadow is shown on the posterior edge of the breast
• The nipple should be in profile
• Symmetrical images
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Positioning. CC view
• The film support table in the correct height for the woman
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Positioning. CC view
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Positioning. MLO view
• All the breast tissue clearly shown
• Pectoral muscle to nipple level
• Symmetrical images
• Nipple in profile
• Inframammary angle clearly demonstrated
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Positioning. MLO view
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Positioning. MLO view
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Positioning. MLO view
Key aspects to achieve a high quality MLO view :
• height of the breast support table,
• the angle being used,
• the lift, spread and compression of the breast
• and the comfort of the woman..
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60o45o ?Positioning. MLO view
30o
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45-60o
Positioning. MLO view
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30-45o
Positioning. MLO view
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Positioning. MLO view
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Overlying artefacts e.g. spectacles, shoulders
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Overlying artefacts e.g. hand, hair
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Overlying artefacts e.g. skin folds
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Compression
• Less scattered radiation - betterthe contrast of the images
• Reduction the overlapping of tissue shadows - better visualisation of the breast tissue
• Lower radiation dose
• Probability of blurring due to movement is reduced
100N 200N 300N ?
(10 kg 20 kg 30 kg) ?
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King-size breasts: MLO – deep prepectoral tissue visualisation
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King-size breasts: CC – nipple visualisation
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Augmented breasts – implants included
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Augmented breasts – implants included
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MLO CC
Augmented breasts – implants excluded
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Augmented breasts – implants excluded
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Social skills
• Communication between the radiographer and the woman is one of the most important aspects of the examination.
• Radiographers play a key role in optimising the woman’s experience, satisfaction and continued acceptance and uptake of the service.
• The radiographer must be friendly, caring and generate confidence in the woman.
• In a pleasant, calm and informative atmosphere the woman is more likely to relax.
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Radiologist ensures :
• High level of image quality• a satisfactory quality assurance system
• sufficient quality control mechanisms
• Sufficient radiological performance levels • effectively advancing the time of diagnosis of cancers
• and lowering the rate of advanced cancers
• Minimised the adverse effects of screening
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Radiologist. Image quality
• All necessary physical-technical and professional quality control processes are continuously carried out
• Assess before reporting on the mammogram if the proper positioning techniques were used by the radiographer
• Be familiar with the important aspects of exposure and processing techniques (which play a vital role in final image quality in analogue setting)
• Ultimately, must be resolute in refusing to accept mammograms not meeting sufficient criteria for adequate diagnosis.
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Viewing conditions
• Reading environment • undisturbed • control of background room light • no unnecessary light glaring from the film viewer
• Previous mammograms at the time of screen reading :• increasing cancer detection by the ability to perceive changes in appearance
between examinations,• reducing unnecessary recall to assessment for long standing benign lesions
• Double reading increases sensitivity of the screening test by 5-15%
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Full Field Digital Mammography (FFDM) withSoft Copy Reading
For the soft-copy reading in a screening programme are mandatory :
• optimal reading environments,
• high resolution monitors,
• user-friendly image display
• Feedback of results at all stages is an important learning and quality enhancing process and mechanisms should be in place to achieve this
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Reduction of adverse effects
• Unnecessary recalls • are costly, • cause psychological discomfort to the woman, • may result in unnecessary biopsies.
• Recalled cases should be reviewed and the positive predictive value for malignancy determined for each category of mammographic abnormality
• Delay • in communicating results,• performing assessment or surgery -
is likely to cause distress and anxiety.