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Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


There are both benets and risks associated with most medical procedures. Medical imaging, especially imaging that exposes patients to ionizing radiation, is no exception. The goal of medical imaging is to provide the most useful medical information, at the lowest risk commensurate with providing that information. Mammography exposes the breast, one of the tissues most sensitive to ionizing radiation. Therefore, it is important to determine what level of image quality is required to permit appropriate medical decision making and consequently how much radiation is required. In this Report the technical aspects of mammography are reviewed in detail and the principles of mammographic image quality are discussed with emphasis on the connection between image quality and absorbed dose to the breast tissue. The newly emerging modality, digital mammography, is also considered in some detail. While the importance of quality control (QC) for mammography is emphasized, there are several excellent publications on this topic so it is not covered extensively. Instead, what is provided is an outline of the aspects of imaging performance that should be tested upon installation of the equipment (acceptance testing) and periodically during its use (routine QC). As well, in the Appendices, some of the major QC programs in various countries or regions are described along with examples of test tools used in those programs. This Report is intended for healthcare policy decision makers, radiologists, referring physicians, medical physicists, and medical imaging radiographers (technologists). Mammography is widely used in many countries, with the potential of a large benet in reducing mortality from breast cancer and facilitating the management of this disease. The principles discussed in this Report should be helpful to the reader in helping to provide this benet while reducing radiationrelated risks to acceptable levels.

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# International Commission on Radiation Units and Measurements 2009

Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


1. Introduction
Mammography plays an important role in the detection and diagnosis of breast cancer as well as in localization for biopsy and therapy. Earlier detection has contributed to reduction of mortality from breast cancer. To realize the benets of mammography it must be carried out on high-quality equipment that is properly maintained and calibrated. The examinations must be performed by welltrained radiographers and interpreted by skilled radiologists with specialized experience in mammography. The physics of image formation has been studied extensively, and the principles of achieving high quality are well understood. Modern mammography is accomplished using a fairly complex system of technology in which the x-ray source size, the x-ray spectrum produced, the beam geometry, breast compression, image receptor (the device used to absorb x rays transmitted by the breast and acquire the image), image processing and viewing components have all been chosen to maximize the possibility of detecting small breast cancers. While mammography is the most widely used imaging modality for the breast, other imaging tools such as ultrasound and breast magnetic resonance imaging (MRI) provide complementary information to facilitate accurate diagnosis by discovering some cancers not visible on mammography, by revealing the true extent of disease or by ruling out false positive ndings on mammography. New techniques such as digital mammography, tomosynthesis and computer-aided detection and diagnosis can further increase the accuracy of mammography. The benets of any medical imaging procedure must be balanced against any risks imposed by the procedure. In the case of mammography, the main benets are: reasonable reassurance that breast cancer is not present (in the case of a negative examination result) or earlier detection of breast cancer and the possibility of reduced mortality or morbidity associated with treating less-advanced disease in the case of a positive test. The risks include false reassurance that cancer is not present (a false-negative examination), and unnecessary concern that cancer might be present when in fact it is not (false-positive examination). Because mammography delivers a dose of ionizing radiation to the breast, the risk of radiation-induced breast cancer must also be considered. Maintaining the mammography system in its optimum condition requires implementation and regular performance of a quality assurance program in which technical quality control testing is conducted at regular intervals. Performance problems discovered through these tests should be attended to through prompt action to restore the equipment to proper operating specications in a timely manner. No medical examination has experienced as much controversy as x-ray mammography (ACS, 2003; Ernster and Kerlikowske, 1999; Feig, 2002; Kopans, 2003; US Preventive Services Task Force, 2002). This is especially true with respect to its use for screening asymptomatic women (Berrington de lez and Reeves, 2005; Miller, 2001; 2003; Gonza bar et al., 2003). Concerns have been expressed Ta both in relation to its efcacy and the potential risk associated with the absorbed doses received. However, the value of mammography has now been demonstrated in several studies. Nevertheless, it is important that it is carried out in an optimized manner, i.e., that the image quality be optimum for the task of detection and diagnosis of breast cancer and that the dose received be as low as is possible, consistent with achieving the required level of image quality. This Report considers these issues as well as those pertaining to the quantication of image quality in mammography.

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# International Commission on Radiation Units and Measurements 2009

Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


2. Mammography in Clinical Practice

Mammography is an x-ray imaging procedure for examining the breast. It is used primarily for the detection and diagnosis of breast cancer, but also for the guidance of needle biopsies and pre-surgical localization of suspicious areas. by the lactiferous duct opening onto the nipple. Within each lobe there are multiple lobules. The terminal ductal lobular unit is the site of origin of most breast disease and is normally only about 3 mm to 5 mm in size. It consists of the extralobular terminal duct and the lobule. The latter is comprised of the intralobular terminal duct and the acini. The arterial supply is primarily from the lateral thoracic and intercostal arteries with branches from the internal mammary artery. The lymphatic system is the route of spread of breast cancer to other parts of the body. The lymphatic vessels drain primarily to the axillary, interpectoral, supraclavicular, and internal mammary nodes. However, there is also free communication to the opposite breast and into the abdomen. The breast is vestigial in children and men and develops at puberty in women due to stimulation by estrogen and progesterone from the ovaries. However, other hormones such as growth and thyroid hormones, the adrenal corticosteroids, and insulin are also required. The uctuation in hormone levels during the normal menstrual cycle results in the cyclical proliferation then atrophy of the hormone-sensitive tissues in the breast. This might have an effect on the development of pathological conditions. At menopause, the loss of estrogen and progesterone usually results in a decrease in the amounts of epithelial and connective tissue, which is observable in the mammogram. However, the common use of hormone-replacement therapy, other endogenous hormones and drugs might actually result in an increase in the parenchymal and stromal tissues at menopause.

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Breast Cancer

Internationally, breast cancer has been the cancer of highest incidence and mortality in women. More than 1 million were diagnosed with breast cancer internationally in 2002 with more than 477,000 deaths (Parkin et al., 2005; WHO, 2004). The cause or causes of breast cancer are not completely understood; however, it has been demonstrated that mortality is substantially reduced if disease is detected at an early stage bar et al., (Duffy et al., 2006; Smart et al., 1995; Ta 1993; 2003). Although the probability of developing breast cancer increases with a womans age (see Table 2.1), the age distribution of the female population causes the percentage of the total breast cancer incidence to vary only slightly with age between the ages 45 and 64 (see Table 2.2). Mammography is an effective method for detecting early-stage breast cancer. It is used both for investigating symptomatic patients (diagnostic mammography) and for screening of asymptomatic women in selected age groups. In screening, it is the only imaging method that has so far been demonstrated to contribute to reduction of mortality due to breast cancer (Duffy et al., 2006).


Anatomy and Physiology of the Breast


Pathology of the Breast

The mammogram must accurately represent the anatomy of the breast, illustrated in Figure 2.1. The breast is a compound exocrine-modied sweat gland that rests on the pectoralis muscle of the anterior chest wall. It can extend from the midaxillary line laterally to the sternum medially and from the second to the sixth costal cartilage. The basic structure of the breast is the lobe that drains

The most signicant disease of the breast is cancer. For most women a breast problem can be classied as being due to cancer or not due to cancer, with the actual cause of the latter being less important. Breast cancer is the commonest cancer and the second commonest cause of cancer death in women in western countries. In these countries, the incidence continues to increase

# International Commission on Radiation Units and Measurements 2009


Table 2.1. Probability of a woman developing breast cancer at different ages Age group , 40 40 49 50 59 60 69 . 70 Total Probability of developing breast cancer (%) 0.48 1.43 2.5 3.5 3.88 12.28

Data from DevCan (2005) and Horner et al. (2009).

Table 2.2. Age distribution of female breast cancer incidence Age group , 45 4554 5564 . 65 Total Relative incidence of breast cancer (%)

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10 23 28 39 100

Data from Horner et al. (2009).

slightly, while the mortality rate has declined slightly since 1985 and more so since 1990. More recently, a reduction in breast cancer incidence for the year 2003 was reported (Ravdin et al., 2007). It is speculated that this might be due to reduced use of hormone-replacement therapy. Breast cancer in men does occur but accounts for less than 1 % of breast cancers. Most breast cancers are carcinomas that arise in the epithelium of the terminal ductal lobular unit. Invasive carcinomas are divided into ductal (90 %) and lobular (10 %). In situ carcinomas are those that have not extended beyond the basement membrane of the duct or acinus. Other cancers are uncommon, but, of these, lymphomas and metastases are most likely to be seen.


Radiological Signs of Breast Cancer

The routine radiographic examination consists of the mediolateral oblique and craniocaudal views as illustrated in Figure 2.2. The primary radiographic signs of malignancy are calcications, masses, asymmetrical or new densities, and architectural distortion. Secondary changes can occur in the nipple, skin, and lymph nodes. Correlation with the clinical history and physical ndings is necessary. The American College of Radiology has established a standardized system and terminology for reporting mammographic ndings. The Breast Imaging Reporting and Data System (BI-RADS)

Figure 2.1. Anatomy of the breast. (a) A schematic lateral view of the breast. (b) A mediolateral oblique projection mammogram in which a number of anatomic structures are identied: (A) pectoralis muscle, (B) nipple, (C) adipose tissue, (D) glandular tissue, (E) blood vessel, (F) lymph node, (G) Coopers ligaments, (H) latissimus dorsi muscle. From NCRP Report 149 (NCRP, 2004).

Mammography in Clinical Practice

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Figure 2.2. Illustrative mammograms. (a) Craniocaudal view. ( b) Mediolateral oblique view.

(ACR, 2003) provides nomenclature for describing radiological signs of malignancy and benign disease. 2.4.1 Calcications

Calcications are evaluated according to their distribution (location and number) and morphology (size, shape, and density). Calcications that are bilateral, symmetrical, or diffuse in distribution are more likely benign as in brocystic changes. Those that are unilateral, linear, segmental, or clustered are of greater concern. Benign calcications tend to be smooth, round, sharp, lucent-centered, dense, or coarse such as in broadenomata. Those of intermediate concern are more amorphous, indistinct, or coarse-heterogeneous. Malignant calcications tend to be ne-pleomorphic, irregular, linear, and branching. Calcications of ductal carcinoma in situ can be quite characteristic. However, there is overlap between benign and malignant appearances that can often be claried only by further radiographic images, usually coned compression magnication views or biopsy. Percutaneous stereotactic guided core or vacuum-assisted biopsy is indicated in some cases. As these calcications can be only a few hundred micrometers in diameter, it is extremely important to have excellent image quality that allows their identication and characterization. 2.4.2 Masses

importantly on their shape and margin. There is a considerable variability, but generally a solitary dominant lesion is of more concern than multiple small similar masses. Masses are evaluated as being high, equal, or low density compared to an equal volume of broglandular tissue. Masses containing radiolucent fat are very likely to be benign, such as an intramammary lymph node or a hamartoma. Masses that are relatively dense for their size compared to normal breast tissue raise more suspicion. The BI-RADS descriptors for shapes as being round, oval, lobular, and irregular reect, in that order, increasing suspicion. Similarly, the level of concern ascribed to margins of masses increases in the following order: circumscribed, obscured, microlobulated, indistinct, to spiculated. Typically benign common masses might be cysts or broadenomata. To be able to appreciate these features requires images that have been produced with optimum exposures, contrast, and resolution. Additional mammographic coned views and an ultrasound examination can be used for further assessment. 2.4.3 Asymmetry

Masses are assessed according to their location, size, number, and relative density, but more

The asymmetry refers to the difference in volume or relative density of breast tissue or prominent ducts. The need is to determine if the nding is due to normal breast tissue or an obscured mass using the same tools as for masses. To nd new asymmetries requires comparison with the opposite breast and with any previous examinations that can be obtained.



Architectural Distortion

Architectural distortion is seen as straight lines radiating from a central area and retraction or bulging of a contour. Architectural distortion is often subtle and difcult to perceive without highquality images. Its causes can be benign or malignant, and careful correlation with the history and physical ndings must be done. Surgical scars can cause a very suspicious appearance. Again additional mammographic views and ultrasound evaluation might be necessary. 2.4.5 Other Signs

Intramammary and axillary lymph nodes are noted for abnormalities in size, shape, and the absence of the normally fatty hilum. Skin thickening or retraction and nipple retraction are also signs of concern.

the Australian program accepts women from age 40 (Barratt et al., 1997). Screening has been shown to be benecial for those up to the age of about 74 years. American recommendations for screening women at very high risk due to genetic mutations or signicant family histories of breast or ovarian cancer have recently been published (Saslow et al., 2007). There is now strong evidence (Kriege et al., 2004; Kuhl et al., 2005; MARIBS, 2005; Warner et al., 2004) that contrast-enhanced breast magneticresonance imaging (MRI) is a more accurate method for screening these women and is recommended in addition to mammography. However, if mammography is used for this purpose, the commonly accepted ad hoc recommendations are to begin mammographic screening at approximately 10 years prior to the age of diagnosis of breast cancer in the rst-degree relative.

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2.5 2.5.1

Indications for Mammography


Role of Ultrasound

Symptomatic Women: Diagnosis

Mammography is used to investigate breast symptoms as well as the ndings detected on screening mammograms or clinical examination. This would include women in the following situations: Possible abnormality on screening mammograms. Women over 40 years of age with breast implants. Palpable mass. Ultrasound is the imaging modality of choice for a mass in the woman under 30 years of age, pregnant, or lactating. Unilateral nipple discharge from a single orice that is serous or bloody. Skin changes, such as dimpling or rash. Nipple inversion, deviation, or rash. Axillary lymphadenopathy. Metastatic adenocarcinoma of an unknown primary source. Severe persistent focal pain or tenderness unrelated to the menstrual cycle. Previous treatment for breast cancer. 2.5.2 Asymptomatic Women: Screening

Screening mammography is done to detect unsuspected breast cancer in asymptomatic women. In those women with an average risk of breast cancer, annual or biennial mammographic screening is performed in some jurisdictions for women 40 years of age or older. For example the screening programs in 8 of 10 Canadian provinces accept women at age 40 (PHAC, 2006). Similarly,

In ultrasound breast imaging, a piezoelectric transducer is used to create a series of short pulses of focused sound (mechanical waves) in the frequency range 7.5 MHz to 15 MHz. By coupling the transducer to the breast with a gel, the pulses propagate into the breast, and part of their energy is reected from tissue interfaces encountered along their path, so that a single pulse will provide multiple reected pulses. These pulses travel back towards the transducer, which is switched into receiving mode to convert the returning energy into a radio-frequency electrical signal. The total time between emission from the transducer and detection of the energy is proportional to the round-trip distance between the transducer and a particular tissue structure, and inversely proportional to the speed of sound in the tissue. From the timing of the returning pulses and their strength, an image can be formed containing information on the morphology and mechanical properties (e.g., stiffness) of the tissue. Advantages of ultrasound imaging are that it is not adversely affected by radiographically dense tissue, it does not require the use of ionizing radiation, and it is relatively inexpensive. Furthermore, the images are inherently tomographic, and so are free from the problems of superposition that can limit the effectiveness of mammography. Compression of the breast is not necessary. On the other hand, one of the limitations of ultrasound is that it is highly operator dependent. This makes it less reproducible. Therefore, a physician should either conduct the examination or be close at hand to

Mammography in Clinical Practice

supervise it. Ultrasound is also less effective than mammography in demonstrating microcalcications. Indications: As the rst imaging modality to evaluate a palpable mass in women , 30 y, lactating, or pregnant. As an ancillary modality to investigate a clinical or mammographic nding, to assess extent of malignant disease including the axilla, to distinguish between cystic and solid lesions, to look for unknown primary adenocarcinoma, to evaluate serous or bloody nipple discharge, to assess implant integrity. To guide ne-needle aspiration of cystic and solid lesions. To guide large-core needle biopsy and preoperative wire localization. Although ultrasound can sometimes detect small invasive carcinoma not evident on mammography, its use for routine screening has not been scientically validated at this time. Research into its use to screen women at high risk for developing breast cancer and with mammographically dense breasts continues. Ultrasound guidance is the method of choice for core-needle biopsy of ultrasound-visible lesions even if they are seen on other modalities. It is primarily used to obtain tissue for pathological diagnosis of a mass, including the mammographically occult mass that might be associated with calcications.

resonant frequency or phase of the RF signal with position in the patient. Through Fourier transform analysis, the positional dependence of the origin of signals can be deduced and an image can be reconstructed. Cancers and other abnormalities can stimulate the growth of new, poorly formed blood vessels (tumor neoangiogenesis). In breast MRI, leakage and pooling of an intravenously injected paramagnetic contrast agent (gadolinium DTPA) from these vessels in the vicinity of a tumor affect the magnetic properties of protons in tissue water nearby, and these changes are imaged. MRI has been demonstrated to be very sensitive in the detection of breast cancer. It is particularly useful in high-risk women, for example those who carry genetic mutations that place them at ten-fold elevated risk of breast cancer compared to the general public. It is considerably more sensitive than either ultrasound or mammography in these women, and, when combined with one or both of these modalities in a screening regimen, it provides almost 100 % sensitivity in detecting breast cancer (Kuhl et al., 2005; Kriege et al., 2004; Leach et al., 2005; Lehman et al., 2005; Saslow et al., 2007; Warner et al., 2004). Currently, however, its specicity is low compared to mammography, resulting in a higher than desired false-positive yield in screening. Indications: Screening of women at very high risk for breast cancer because of genetic mutations. To look for an unknown primary adenocarcinoma. To determine extent of malignancy primary or residual. To monitor response to neoadjuvant chemotherapy. To differentiate recurrent malignancy from a scar. To address problems in mammographically dense breasts. To assess implant integrity. 2.8 Clinical Qualitative Evaluation of the Mammographic Process

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Role of MRI

Magnetic-resonance imaging (MRI) can be highly effective in detecting breast cancer. In breast MRI the patient lies prone within the bore of a powerful electromagnet. This is often of the superconducting type with a eld strength of 1.5 or 3 Tesla. This causes the magnetic spins of the protons, primarily in water, in the body to align with the strong magnetic eld. A series of magnetic-eld gradients and radio-frequency (RF) pulses (referred to as a pulse sequence) is then used to stimulate the protons and reorient their magnetic spins. As the excited proton spins relax to realign with the main eld, they emit RF electromagnetic energy. The strength of the signal and the relaxation times of the protons reveal information about their environment, which varies according to tissue type and is often different between healthy and malignant tissues. Clever design of the pulse sequence and switching of gradient elds provides variation of

Professional and government organizations have set standards for the practice of mammography. In several countries (the USA, UK, Australia, New Zealand, Canada, Japan, Latin American countries), peer review of clinical image quality is performed as part of an accreditation process (CAR, 1998; 2008; Hendrick, 1999; McLelland et al., 1991; Moore et al., 2005; Morimoto et al., 2004; Terada, 2002; Workman et al., 2006). Images are assessed by the radiologist or a quality-control radiographer for positioning, compression, exposure, contrast, sharpness, noise, artifacts, and examination identication according to the criteria discussed below.


Positioning. The objective is to maximize the amount of breast tissue examined. The mediolateral oblique view must show adequate visualization of posterior tissues, no sagging at the inframammary fold, and the pectoral muscle should be within 2 cm of the nipple line. The craniocaudal view should show no excess exaggeration medially or laterally. No portion of the breast should be excluded from the mammogram, and there should be no skin folds or other body parts projected over the breast. Compression. Compression is adequate if there is good separation of parenchymal densities with uniform exposure levels and no patient motion. Exposure. A proper exposure provides adequate penetration of dense and fatty parts of the breasts, but does not generally over-expose or under-expose the image receptor for any region of the breasts. It must be possible to identify microcalcications within or superimposed on dense broglandular tissue. Contrast. There should be adequate contrast between the fatty and broglandular parts of the breast over as much of the breast as possible. Sharpness. Image should have sufcient sharpness (spatial resolution) to provide good delineation of linear structures, feature margins, and microcalcications. High spatial resolution is necessary to both identify and characterize lesions. Noise. The image should not contain excessive uctuation in signal (either random or caused by diagnostically irrelevant structures) that could limit visualization of ne detail needed for diagnosis. Artifacts. Images are evaluated for the presence of artifacts related to screens, grids, handling, processing, and foreign substances. These could obscure signicant ndings. Examination identication. The images should be properly identied with the patients name, a unique identier such as birth date or facility registration number, facility, date, mammographic view and axillary side, cassette, and technologist who performed the examination.

terminology by the American College of Radiology. The BI-RADS covers the areas of mammography, ultrasound, and MRI (ACR, 2003). There are recommendations for mammographic descriptors of masses, calcications, and architectural distortion, with special cases and associated ndings. The location of lesions should be identied by clockface, quadrant, and depth with some special terms. There are also recommendations for the structure of a report. This report should include the indication for the examination, a reference to breast composition, a description of any signicant nding, comparison with prior examination (if necessary), and an overall impression. The use of nal assessment categories indicates to the clinician the level of concern for malignancy and provides management recommendations.

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The Mammographic Examination

As described in Section 2.4, breast cancer is detected on the basis of four types of signs on the mammogram: the characteristic morphology of a tumor mass, certain presentations of mineral deposits called microcalcications, architectural distortion of normal tissue patterns caused by the disease, and asymmetry between images of the left and right breast. Detection of these features depends critically on the quality of the mammogram. It is necessary to have adequate contrast, latitude (dynamic range), and spatial resolution in the image to see details of the skin, nipple, subcutaneous and retromammary fat, broglandular tissue, supportive connective tissue, and pectoralis muscle. In order to be able to discuss factors affecting the quality of mammography, a brief review of the principles of mammographic imaging is presented in the next section. There are several excellent textbooks on the clinical aspects of mammography, and breast ultrasound and MRI (e.g., Bassett et al., 2005; Morris bar and Liberman, 2005; Stavros et al., 2005; Ta et al., 2004).



The need to clearly communicate the radiologists interpretation to the referring physician has resulted in the development of standardized


Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


3. Production of the Mammogram

The mammogram is formed when x rays from a quasi-point source irradiate the breast, and the transmitted x rays are recorded by an image receptor. Because of the spreading of the x rays from the source, structures are magnied as they are projected onto the image receptor. The signal is a result of differential attenuation of x rays along paths through the structures of the breast. The essential technical requirements of highquality mammography are: to include as much of the breast tissue as possible on the mammographic image, to provide adequate contrast in the image of all parts of the breast to allow detection of the differences in x-ray attenuation between normal breast tissue and cancer, to obtain sufcient spatial resolution to allow visualization of the ne detail associated with the signs of breast cancer, to control the level of random uctuation (noise) in the image, thereby facilitating the reliable detection of cancer, and to maintain the absorbed dose to the breast at the lowest level consistent with achieving the above. The essential features of image formation are summarized in Figure 3.1. Figure 3.1a depicts a simplied schematic model of the breast in mammography (Fahrig et al., 1992), and Figure 3.1b illustrates a one-dimensional prole of x-ray transmission through the breast, based on this model. A region of reduced transmission corresponding to a structure of interest such as a tumor, a calcication, or normal broglandular tissue is shown. The imaging system must have sufcient spatial resolution to delineate the edges of ne structures in the breast. Typically, it is desirable to resolve a structural detail as small as 50 mm. Variation in x-ray attenuation due to differences in tissue composition and mass density gives rise to contrast. The detectibility of structures providing subtle contrast is impaired, however, by random uctuations in the prole, referred to as mottle or noise. The imaging system must have adequate dynamic range to demonstrate subtle differences in tissue composition and density, both near the edge of the breast where there is very little attenuation (high signal), and in the center of the breast where the mean signal might be reduced to as low as 1 % of its value in the absence of attenuation1. Because the breast is sensitive to ionizing radiation, which, at least for high doses, is known to cause breast cancer, it is desirable to use the lowest absorbed dose compatible with the required diagnostic image quality.

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Physics of Image Formation

In the model of Figure 3.1a, a breast composed of a mixture of adipose tissue and broglandular tissue is considered. For the simplied case of monoenergetic x rays of energy E, with a linear attenuation coefcient of the tissue, m(E), and in which, for the moment, the detection of scattered x rays is neglected, the number of x-ray photons recorded in an area of xed size in the image background is proportional to Nb E N0 E hE emEt ; 3:1

and the number recorded in the shadow of the lesion or other structure of interest is Nlesion E N0 E hE emEtTm ET :


In Eqs. (3.1) and (3.2), N0(E) is the number of x rays that would be incident on that area of the detector in the absence of tissue in the beam, m(E) and m0 (E) are the linear attenuation coefcients of the breast tissue and the lesion, respectively, t is the thickness of the breast, and T is the thickness of the lesion. The factor h(E) is the x-ray quantumdetection efciency of the detector, given by:

hE 1 emd Etd ;


Such as in a 7 cm thick compressed breast composed of 60 % broglandular tissue [m(20 keV) 0.80 cm21] and 40 % adipose tissue [m(20 keV) 0.46 cm21]. Attenuation coefcients from measurements of Johns and Yaffe (1987).

# International Commission on Radiation Units and Measurements 2009


Figure 3.3. Calculated radiation contrast for a 5 mm thick tumor, and for a 0.2 mm thick microcalcication. Dashed line: 5 mm tumor; continuous line: 0.2 mm calcication.

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Figure 3.1. (a) Simple model of the breast. The bulk of the breast tissue is assumed to consist of a uniformly distributed mixture of specied proportions of broglandular tissue and adipose tissue, by mass. (b) One-dimensional prole of x-ray transmission through this breast model.

To gain some insight into the primary factors responsible for radiation contrast, we assume that the x-ray beam is monoenergetic and continue to ignore the detection of scattered radiation. Under such conditions, the radiation contrast would be Cns 1 eDmt ; 1 eDmt 3:5

Figure 3.2. Linear x-ray attenuation coefcients of tissues within the breast, plotted versus x-ray energy. Tumor tissue is inltrating ductal carcinoma. Data are from Johns and Yaffe (1987). Solid line: inltrating ductal carcinoma; dashed line; broglandular tissue; dotted line: adipose tissue.

where md(E) is the linear attenuation coefcient of the active (i.e., signal-producing) x-ray absorbing layer in the detector and td is its thickness. The difference in x-ray transmission gives rise to radiation contrast, which can be dened as  2 Nb Nlesion =Nb Nlesion ; Cns DN = N 3:4 (Nb Nlesion) / 2, and where DN Nb 2 Nlesion, N Cns ignores effects of scattered radiation.

i.e., contrast, in this simplied situation, would depend only on the thickness of the lesion and Dm, the difference between the linear x-ray attenuation coefcient of the lesion and that of the background material. Shown in Figure 3.2 are x-ray attenuation coefcients as functions of x-ray energy, determined from measurements on samples of three types of materials found in the breast: adipose tissue, normal broglandular breast tissue, and inltrating ductal carcinoma (one type of breast tumor) (Johns and Yaffe, 1987). Both the attenuation coefcients themselves and their difference (m 0 2 m), decrease with increasing E. As shown in Figure 3.3, which is based on Eq. (3.5), Cns falls as x-ray energy increases. Note that the radiation contrast of a small calcication in the breast is similar to that for a tumor, because of the greater difference in attenuation coefcient between calcium and breast tissue. This is due to the relatively higher atomic number of the calcium, which increases the cross section for photoelectric absorption. As energy increases, the importance of the photoelectric effect diminishes, and the contrast of the microcalcication falls below that of the tumor. For a given image recording system (image receptor), a proper exposure requires a specic value of

Production of the Mammogram

Figure 3.5. Basic beam geometry for mammography. (a) Correct alignment. (b) Incorrect alignment, illustrating a tissue cutoff that would occur if a centered beam were used.

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Figure 3.4. Schematic diagram of a mammography system.

3.2 3.2.1

Equipment for Mammography

The X-Ray Unit

x-ray energy uence transmitted by the breast and incident on the receptor, i.e., a specic value of Nb into a given area. The breast entrance air kerma, Ka,e (see Section 6.1.2), required to produce an image is, therefore, proportional to Ka;e / Nb emEt : 3:6

Because m decreases with energy, the required exposure for constant signal, Nb, at the image receptor will increase if E is reduced to improve image contrast. A measure of the risk of radiation-induced breast cancer better than entrance air kerma is the mean glandular dose (MGD), DG (ICRU, 1998; 2005; NAS/NRC, 2006). DG is calculated as DG Ka;e cG;Ka;e ; 3:7

where cG,Ka,e is a conversion factor, described in ICRU Report 74, Appendix E (ICRU, 2005), obtained experimentally or by Monte Carlo radiation-transport calculations, which converts entrance air kerma to MGD in a simulated breast of specied composition and thickness (Wu et al., 1991). The conversion factor increases with E, so that the MGD does not fall as quickly with energy as does entrance air kerma. The trade-off between image contrast and absorbed dose necessitates important compromises in establishing mammographic operating conditions. Dosimetry in mammography is discussed further in Section 6.

The components of the imaging system will be described briey here, while their design will be related to the imaging performance requirements of mammography in later sections. The mammography unit consists of an x-ray tube and an image receptor mounted on opposite sides of a mechanical assembly or gantry. Because the breast must be imaged from different aspects and to accommodate patients of different height, the height of the assembly can be adjusted, and it can be rotated about a horizontal axis as shown in Figure 3.4. Most general radiography equipment is designed such that the image eld is centered below the x-ray source. In mammography, the systems geometry is arranged as in Figure 3.5a, in which a vertical line from the x-ray source grazes the chest wall of the patient and intersects orthogonally with the edge of the image receptor closest to the patient. If the x-ray beam were centered over the breast as shown in Figure 3.5b, some of the tissue near the chest wall would be projected inside of the patient where it could not be recorded. X rays for mammographic imaging are produced in a specially designed tube. Electrons emitted by a heated cathode assembly are accelerated in an electric eld and focused to strike a positively charged anode. The area on the anode upon which the x rays impinge is referred to as the target or focal spot, and it is made of a material such as molybdenum, rhodium, or tungsten, the choice of which depends on the desired x-ray spectrum. The spectrum consists of both bremsstrahlung radiation and characteristic x rays specic to the target material.


Figure 3.6. Schematic of the anode of a rotating-anode x-ray tube, illustrating the angled surface on which the target material is deposited and the reference axis used for specication of focal-spot size by manufacturers.

mammogram than toward the chest wall side. The resultant variation in x-ray uence along the nipple chest wall axis is referred to as the heel effect. Radiation leaving the x-ray tube passes through a tube port, generally composed of beryllium, a metallic spectrum-shaping lter, a beam-dening aperture, and a plastic plate, that compresses the breast. The compression plate should be reasonably rigid and compress the breast to a uniform thickness, although some manufacturers have employed tilting paddles to improve positioning. Those photons transmitted through the breast and the breast-support platform are incident on an anti-scatter grid and then pass through the housing of the image receptor, nally being incident on the image receptor, where they interact and deposit most of their energy locally. Mammography systems are designed to minimize the distance between the breast and the image receptor to keep the magnication factor low and avoid increasing the geometric unsharpness. 3.2.2 Automatic Exposure Control

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Both the continuous spectrum of bremsstrahlung photons and the monoenergetic characteristic x rays are usually referred to in this case as x rays. In modern mammography systems, a high-frequency ( ! 20 kHz) voltage waveform is used to excite x-ray production (Barnes, 1991). This waveform provides an almost constant potential to the tube.2 Typically, potentials ranging from about 20 kV to 40 kV, chosen according to the thickness and composition of the breast, are applied to the tube for clinical imaging. Because of the relatively low energy of electrons used in mammography, the efciency of x-ray production is very low, and most of the kinetic energy of impinging electrons is dissipated in the anode as heat. To accommodate this heat while allowing the effective focal spot size used in image formation to be small, the target is formed on the surface of a rotating anode disk, and the anode is tilted with respect to the incident electrons (see Figure 3.6) so that the heat is spread over a greater area. Depending on their angle of emission, x rays formed in the target material must, therefore, traverse different path lengths through the target in traveling from their point of production to the image plane. Referring to Figure 3.6, it is seen that this causes there to be greater attenuation of x rays traveling toward the nipple side of the

For this reason, in the remainder of this Report, excitation voltages will be referred to simply in terms of kV rather than peak kV.

It is difcult for the technologist to estimate the attenuation of the breast by inspection, and, therefore all mammography units should be equipped with automatic exposure control (AEC). The AEC sensor is located behind the image receptor so that it does not cast a shadow on the image. The sensor detects the small fraction of the x-ray uence that is transmitted through both the breast and the receptor and provides a signal used to discontinue the exposure when a certain preset amount of radiation has been received by the image receptor. The location of the sensor must be adjustable so that it can be placed behind the appropriate region of the breast in order to obtain proper image signal in that region. For lm mammography, AEC devices must be calibrated so that constant image optical density (OD) is obtained, independent of variations in breast attenuation caused by spatial variations in tissue composition and thickness, kilovoltage setting, or eld size. A different approach is required for digital systems for which the image brightness and contrast are readily adjustable using the computer display. Here, the exposure level is set to achieve a desired image signal-to-noise ratio. This will be discussed further in Section 5. The signal from the sensor of the AEC is inuenced by point-to-point inhomogeneity in attenuation of the breast tissue. Therefore, the size of the sensor and the position at which the sensor is placed under the breast can have a large effect on

Production of the Mammogram

Figure 3.7. Schematic representation of a mammography screen-lm image receptor. A system employing a single intensifying screen and a single-emulsion lm is shown.

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the exposure used to acquire the mammogram. In addition, with modern equipment, AEC is computer controlled so that relatively sophisticated corrections can be made during the exposure for nonlinear characteristics of the lm (Haus and Jaskulski, 1997).

Figure 3.8. Characteristic (H&D) combination for mammography.





Screen-Film Mammographic Image Receptor


Magnication Mammography

In order to increase the visibility of structures within the breast, geometric magnication with or without localized compression is often used. Magnication mammography is performed by increasing the distance from the breast to the image receptor. This is accomplished by mounting a radiolucent spacer on the image receptor housing and positioning the breast on the surface of this spacer. The main purpose of magnication in this application is to render the projection of the anatomy larger with respect to the limited spatial resolution and noise properties of the screen-lm system and, in particular, to reduce the effect of noise on visualization of ne detail (Doi and Imhof, 1977; Sickles et al., 1977). Magnication increases the effect of geometric unsharpness (Haus, 1977), and to avoid excessive reduction of spatial resolution (see Section a smaller focal spot is necessary. Typically a nominal spot size of 0.1 mm is used for this purpose compared to the nominal 0.3 mm focal spot normally used for contact mammography. Note that due to manufacturers convention for dening the nominal focal spot size, the actual size of the focal spot is generally markedly larger than the nominal size (Barnes, 1991). This is discussed further in Section

When rst introduced, mammography was carried out using direct-exposure radiographic lm in order to obtain the high spatial resolution required (Egan, 1970). Since the mid-1970s, highresolution uorescent screens have been used to convert the x-ray pattern formed by the breast into a visible-light image. These screens are used in conjunction with radiographic lm, most frequently coated on just one side with photographic emulsion. The conguration for a single screen and singleemulsion lm is shown in Figure 3.7. With this arrangement, the x rays pass through the cover of a light-tight cassette and the lm to impinge upon the screen. Alternatively, the receptor can be a digital detector as discussed in Section 4.2. Screen-Film. The most common image receptor used in mammography has been the screen-lm combination. While the light emission of the screen is linearly related to the amount of absorbed energy from the x-ray beam, the lm has a highly nonlinear characteristic. This is generally described by the characteristic curve of the lm, also known as the HurterDrifeld (H&D) curve (see Figure 3.8), which is a plot of the OD of the processed lm versus the logarithm (base 10) of the light exposure to the lm under specied processing conditions. In some cases, the H&D curve combines the response of the screen and lm together, in which case the abscissa of the plot is in terms of log relative x-ray exposure.


The H&D curve provides information regarding the sensitivity of the image receptor as well as the contrast characteristics of the lm. The steeper the slope or gradient of the curve, the greater the contrast (optical-density diffference) that will be displayed to the viewer. Latitude refers to the range of x-ray exposures (corresponding to paths through the breast experiencing different attenuation factors) that can be accommodated by the lm while providing an acceptable gradient. Further discussion on gradient and latitude will be provided in Section Film Processing. Mammography lm is processed in an automatic processor similar to that used for general radiographic lms. It is important that the development temperature, development time, and rate of replenishment of the developer

chemicals be compatible with the type of lm emulsion used and be designed to maintain good contrast of the lm. These factors affect the characteristic response curve of the lm in terms of its sensitivity, gradient, and fog level. Increased time and/or temperature of processing normally provides increased sensitivity and contrast, but at the expense of increased fog. In addition, image noise levels are increased because fewer x rays are used to produce the image in these cases. Proper replenishment is required in order to maintain stability of the processing over time. Replenishment replaces the chemicals carried over from one tank to the next, as well as replacing the used and oxidized chemicals. Adequate xing and washing of the lm to remove all chemical residue is required to ensure the archival quality of the lm.

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Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


4. Digital Mammography
There are several technical factors associated with screen-lm mammography that limit its ability to display the nest or most subtle details and to produce images at the most efcient level of absorbed dose to the patient. In screen-lm mammography, the lm must act as an imageacquisition detector as well as a storage and display device. Because of the sigmoidal shape of the H&D curve of lm (see Figure 3.8), the range of x-ray exposures over which the lm gradient is adequately high, i.e., the image latitude or dynamic range, is limited. If a tumor is located in either a relatively lucent or more opaque region of the breast, then the contrast displayed to the radiologist can be inadequate because of the limited gradient of the lm. This is particularly a concern in patients whose breasts contain large amounts of broglandular tissue, the so-called dense breast. Another limitation of lm mammography is the effect of structural noise due to the granularity of the lm emulsion used to record the image and the spatial nonuniformity of sensitivity of the intensifying screen. This impairs the detectibility of microcalcications and other ne details within the breast. While quantum noise (see Section 5.2.1) is unavoidable, it should be possible to greatly reduce structural noise by technical improvements. Existing screen-lm mammography also suffers because of the inefciency of grids in removing scattered radiation (see Section and because of compromises in spatial resolution versus quantum-detection efciency inherent in the screen-lm image receptor. Many of the limitations of conventional mammography can be effectively mitigated with a digital mammography imaging system, in which image acquisition, display, and storage are performed independently, allowing optimization of each process. For example, acquisition is performed with highly efcient, low-noise x-ray detectors. Because the image is stored digitally, it can be displayed with contrast that is independent of the detector properties but rather dened by the needs of the radiologist. Whatever image-processing techniques are found useful can conveniently be applied, ranging from simple contrast enhancement to histogram modication and spatial-frequency ltering (see Section 4.3 and Pisano et al., 2000a; 2000b). After processing, the digital image can be displayed using either hard-copy or soft-copy methods. In hard-copy display, the image is printed onto a light-sensitive material such as lm, generally by scanning with a ne laser beam. The lm is then viewed on a viewbox. Alternatively, soft-copy display is performed on a high-resolution video monitor. One of the most valuable aspects of digital mammography is that because the data are provided in digital form, it is possible to develop techniques that use the data quantitatively in specialized applications that include image processing, threedimensional image reconstruction (tomosynthesis), and quantitative image analysis. For example, the mammogram can be analyzed using feature identication tools to search for signs of cancer. This approach, called computer-aided diagnosis (CAD), is discussed in Section 4.4.

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Detectors for Digital Mammography

The performance of the digital mammography system depends critically on the characteristics of the x-ray detector. The detector should have the following characteristics: Efcient absorption of the incident radiation beam. Linear response over a wide range of incident radiation intensity. Low intrinsic noise. Adequate spatial resolution. Field of view appropriate to accommodate the range of breast sizes encountered clinically (at least 18 cm 24 cm and preferably 24 cm 30 cm eld size). Adequate sensitivity to avoid excessive patient exposure and to allow acceptable imaging time and heat loading of the x-ray tube. Image display will be discussed in Section 5.3.3.

# International Commission on Radiation Units and Measurements 2009



Types of Digital Mammography Systems

Five main approaches have been taken in the development of digital mammography systems. These vary mainly in the detector design and the x-ray acquisition geometry: photostimulable phosphors (Type 1), active-matrix-readout area detectors with either a CsI phosphor layer (Type 2) or an amorphous selenium layer (Type 3) as the x-ray absorbing medium, signal-integrating slot detectors (Type 4), and quantum-counting slot detectors (Type 5). In the rst three, the entire image is acquired simultaneously, while in the last two systems, only a portion of the image is acquired at one time and the full image is obtained by scanning the x-ray beam and detector across the breast. Area detectors offer convenient, fast image acquisition and can be used with conventional x-ray machines, but can still require a grid. Slot systems are slower, require a scanning x-ray beam, but use relatively simple detectors and have excellent intrinsic efciency at scatter rejection. Digital mammography found its initial application in small area (5 cm 5 cm) systems to facilitate stereotactic breast biopsy (Karellas et al., 1992). These systems use a lens or a beroptic taper to couple a phosphor to a charge-coupled device (CCD) whose format is approximately square and typically provide 1 k 1 k images with 50 mm pixels. Adjustment of display contrast enhances the localization of the lesion, while the immediate display of images (no lm processing is required) greatly accelerates the clinical procedure. Various detector technologies are being used for full-breast digital mammography. These include scintillators coupled to large-area photodiode arrays on an amorphous silicon substrate, scintillators coupled to multiple CCDs, photostimulable phosphors with scanned-laser readout, and a large-area amorphous selenium absorber evaporated onto an amorphous silicon substrate containing an array of detection electrodes and thin-lm transistor (TFT) readout switches. A review of detector technologies for digital mammography is given below. Additional detail can be found in Yaffe (1999). One advantage of scanning systems is that the scattered radiation originating in the breast can be very efciently rejected from the detector, in this way improving contrast and signal-to-noise ratio (SNR) without a signicant dose penalty. Another is that the detector in a scanning system needs only to measure radiation transmitted through part of the breast at any one time, and, therefore, for a given pixel size, fewer detector elements or dels are required than in a full-area system. This can have marked cost advantages.

On the other hand, a scanning system requires longer total exposure time (5 8 seconds), necessitating higher x-ray tube heat loading. Because each part of the breast is exposed for only a very short time, scanning does not cause the type of motion blurring that is seen in screen-lm mammography. However, if the breast moves during scanning, mis-registration artifacts could result. Finally, in a scanning system, the relatively long time required to complete image acquisition restricts the image repetition rate and can be a limitation if dynamic studies are to be carried out. The phosphor-based detectors for digital mammography employ thallium-activated cesium iodide, CsI(Tl), as the x-ray absorber. Cesium iodide can be fabricated as pillar or needle-like structures. These act like ber-optic channels, conducting light produced within the phosphor along the length of the needles, thereby inhibiting lateral spread of the light. It is this spread in a conventional settled phosphor that is a major contributor to resolution loss. The ber-like structure of CsI allows the phosphor to be made thick enough to achieve high quantum-detection efciency without signicant loss of resolution. In principle, one x-ray photon interacting with the phosphor can produce several thousand light quanta. For CsI(Tl), the value is closer to 1600 (Sasaki et al., 2006). If the coupling efciency of the optical-collection system is low, however, the number of electrons produced in the CCD per interacting x-ray can fall to the point at which an additional noise source, called a secondary quantum sink, results. The additional noise will lower the SNR, degrading the quality of the image. In any de-magnifying optics (i.e., optics that reduce the size of the image in coupling to the next stage of the imaging system), either lenses or ber optics, the coupling efciency falls as the degree of de-magnication is increased (Maidment and Yaffe, 1996; Miller, 1991). In practical terms, this limits the de-magnication factor to approximately 2. The ve types of digital mammography systems are described. For convenience, they will be referred to as Type 1, etc., in later sections. Assessments of the performance of commercial digital mammography acquisition systems have been published by Lazzari et al. (2007), Monnin et al. (2007), and Rivetti et al. (2006). 4.2.1 Type 1: Photostimulable-Phosphor System

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The detector in this system consists of a plate, containing an x-ray stimulable phosphor material, typically BaFBr (Crawford and Brixner, 1991; Takahashi et al., 1985). The system is similar in

Digital Mammography

Figure 4.1. A photostimulable-phosphor type (often called CR) digital mammography system. A double-sided plate reading system is shown. Courtesy of Fujilm Medical Systems. Figure 4.2. A CsI-phosphor, at-panel digital mammography system.

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operation to that of the detectors that have been used for over 20 years in digital radiography for applications other than mammography. Absorption of x rays in the material produce energetic photoand Compton electrons in the crystal. These lose some of their energy by exciting loosely bound electrons in the crystal lattice, some of which become trapped in the local potential well of the crystalline phosphor material, where they remain stable for some time. The number of trapped electrons is proportional to the amount of radiation incident on the phosphor. After exposure, the phosphor plate is placed in a reading device where it is scanned with a ne helium neon laser beam (see Figure 4.1). The red light from the laser discharges the traps, causing the electrons to return to their ground state with the release of energy by the stimulated emission of blue light. The blue light can be collected from both the top and bottom surfaces of the plate and measured with photo-multiplier tubes. The resulting signal is digitized to form the image.

commercial phosphor-based at-panel systems has been assessed by Ghetti et al. (2008). 4.2.3 Type 3: Flat-Plate Amorphous Selenium with Electrode Array


Type 2: Flat-Plate Cs(I) with Photodiode Array

In these systems a CsI(Tl) phosphor layer is deposited directly onto a large-area matrix of photodiodes formed on a at-plate amorphous silicon substrate (see Figure 4.2). Each light-sensitive diode element is connected by a TFT switch to a series of control lines and data lines such that the charge produced in the diode in response to light emission from the phosphor is read out and can be digitized. There has been considerable research activity directed toward improvement of the performance of phosphor-based or indirect conversion at-panel detectors (Antonuk et al., 2000; El-Mohri et al., 2007; Rowlands and Yorkston, 2000; Street et al., 2005). The technical performance of several

This system does not employ a phosphor. Instead, x rays are absorbed in a layer of amorphous selenium, which is deposited on an array of electrodes formed on a large-area amorphous silicon substrate (see Figure 4.3). An electric eld is imposed across the plate to collect the electron hole pairs produced in x-ray absorption. The charges drift to the electrode pads and are collected there. During the readout procedure, TFT switches on each detector element (del) are sequentially activated, one row at a time via control lines, and the charge is collected along data lines (running between columns of dels) connecting each detector element to readout electronics, similar to those in a Type 2 system. The design and performance optimization of these so-called direct-conversion atpanel detectors has been discussed by several investigators (Lee, 2006; Polischuk et al., 2001; Rowlands and Yorkston, 2000; Yorker et al., 2002; Zhao et al., 2003). 4.2.4 Type 4: Slot-Scanning CsI Integrating Detector with CCD Readout

In this system (Tesic and Piccaro, 1996; Tesic et al., 1999), a CsI(Tl) phosphor x-ray absorber is coupled through a non-tapered ber-optic plate to several CCD arrays. These are joined end-to-end to create a slot format (see Figure 4.4). Image acquisition is carried out by scanning the detector along an arc across the chest wall beneath the breast. This arc is centered at the focal spot of the x-ray tube,


Figure 4.3. A at-plate amorphous selenium detector system.

Figure 4.5. A slot-scanning system for digital mammography based on a detector that counts individual x-ray quanta.

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a pulse, which is counted to register the absorption of an x-ray quantum. Individual linear detector arrays are arranged adjacently or spaced apart, and the assembly is scanned in a direction orthogonal to the detector lines to acquire the image (see Figure 4.5). The physical performance of the silicon slund detector system has been characterized by A et al. (2007). 4.2.6 Phase-Contrast Digital Mammography

Figure 4.4. Slot-scanning CCD-based digital mammography system.

and during acquisition the x-ray tube pivots about that position with the x rays collimated into a fan beam, matching the area of the detector. As the detector and slot beam move across the breast, the charge produced in the elements of the CCD is shifted down CCD columns at an equal rate, but in the opposite direction, so that the signal resulting from x rays transmitted through a particular path in the breast is integrated in the CCD. When each bolus of signal reaches the last row of the CCD, it is read out and digitized. This technique is called timedelay integration. This system is no longer being produced commercially; however, at the time of writing, there are many units of this type in clinical use. 4.2.5 Type 5: Slot-Scanning Quantum-Counting Gaseous or Solid Detector

In the Type 5 systems, the energy of absorbed x rays is converted to charge in a set of many single-line detectors based on either depleted crystalline silicon or a pressurized high-Z gas in an ionization chamber. The charge is collected to form

The contrast of mammography and the visibility of ne structures in the breast are ultimately determined by the difference in x-ray absorption properties of different breast tissues. Several investigators have shown that it is possible to achieve complementary contrast mechanisms in x-ray mammography through phase contrast attributed to diffraction and refraction effects at tissue boundaries (Burattini et al., 1995; Chapman et al., 1996; Ishisaka et al., 2000; Johnston et al., 1996). The observed effect is a contrast enhancement at edges. While rst demonstrated using monoenergetic x rays generated from synchrotron sources (Arfelli et al., 2000), a more practical implementation has been introduced that allows a conventional x-ray tube with a very small focal spot to be used (Honda and Ohara, 2008; Tanaka et al., 2005). The geometrical arrangement of components employs a large space between the breast and a digital mammography detector. This air gap (see Section provides good scatter rejection, which together with the edge-contrast effect resulting from the phase contrast provides exquisite anatomical detail. 4.2.7 Stereotactic Biopsy Devices

Stereoscopic x-ray imaging techniques are currently used for the guidance of needle biopsies

Digital Mammography

using large-core or vacuum-assisted devices. These procedures can be used to investigate suspicious mammographic or clinical ndings without the need for surgical excisional biopsies, resulting in reduced patient risk, discomfort, and cost. In these stereotactic biopsies, the gantry of a mammography machine is modied to allow angulated views of the breast (typically 158 from normal incidence) to be achieved. From measurements obtained from these images, the three-dimensional location of a suspicious lesion is determined, and a needle equipped with a spring-loaded cutting device can be accurately placed in the breast to obtain tissue samples. While this procedure can be performed on an upright mammography unit, there are also dedicated systems incorporating specially designed tables to allow the patient to lie prone during the procedure. The accuracy of sampling the appropriate tissue depends critically on the alignment of the system components and the quality of the images produced. A thorough review of stereotactic imaging, including recommended quality-control procedures, is given by Hendrick (1999) and by Paquelet (1999).

of the uncorrected heel effect in digital images can affect the results of image-noise measurements in quality-control testing (Alsager et al., 2008). 4.3.2 Resolution Restoration

Blurring in the detector can be partially corrected through image processing by deconvolving the blurring function of the detector. This procedure can be very effective, but if overdone will also enhance image noise. It is therefore important that the inherent detector resolution is adequate and that the image-noise level is acceptable. The latter is accomplished in part through careful design of low-noise detectors and also through appropriate design and use of automatic exposure control and/or automatic technique control. 4.3.3 Additional Image-Processing Operations

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Further image processing is generally carried out to adapt the image for display and interpretation by the radiologist. These image processing operations differ among manufacturers, but can include: (a) Peripheral compensation to atten the signal level at the edge of the breast. This essentially suppresses the effect of thickness reduction near the edge and reduces the dynamic range of image signal that the display system must accommodate, allowing higher contrast settings to be used in image display. It is important that when such software is used it does not unduly distort the contour of the breast. (b) Inversion of the grey scale (black represents high x-ray transmission) and nonlinear transformation (logarithm, square root, etc.) of the image. (c) Other image enhancements, for example histogram equalization. These are also employed to attempt to optimize contrast throughout the breast and best utilize the limited dynamic range of the display system. Image enhancement techniques are proprietary to each vendor and in most cases are selectable at the users discretion. The best way to evaluate these algorithms is to observe the rendition of key structures (spiculations, microcalcications, and margins of benign and malignant lesions) with and without the enhancement activated in a series of sample cases, including images of both dense and fatty breasts. It is also important to know whether the results of image processing are only available locally at the viewing workstation or whether they are preserved so that the enhanced image can be


Image Processing

Image processing is an integral part of all digital mammography systems. Processing operations are applied at several stages in the imaging system. 4.3.1 Flat-Field Correction

The initial operation that takes place is usually a at-eld, uniformity or gain correction. The spatial non-uniformity in detector sensitivity can be corrected by imaging a uniformly attenuating object and creating a gain map that can be used to correct all subsequently acquired images. For atpanel systems and scanning systems, this transformation corrects for non-uniformities in the x-ray eld (e.g., heel effect) as well. In addition, the appearance of bad pixels can be removed from the images. If a single detector element is defective, its signal can be replaced by some weighted combination of signals from adjacent dels. This is acceptable if the defective dels are isolated and few in number, but is of greater concern if signals from entire patches or lines of the detector are absent or incorrect. Manufacturers specify the number and type of such defects that are acceptable. For Type 1 systems, the at-eld correction is currently applied only to the laser readout system and not to the individual phosphor plates or to the x-ray eld. Therefore, artifacts associated with these sources will remain in the images. Presence


viewed elsewhere. Other considerations related to display of digital mammograms are discussed in Section 5.3.3.


CAD for Mammography

There have been several direct and indirect measures of the accuracy of mammography that indicate that the cancer-miss rate is between 5 % and 35 % (Kavanagh et al., 2000; Lewin et al., 2001; Mushlin et al., 1998; Poplack et al., 2000; Taylor et al., 2005). There are four different reasons for misses: (i) the cancer is not visible in the image; (ii) the indications of cancer are very subtle; (iii) the cancer was visible, but was not reported; and (iv) the image quality was substandard due to technical factors related to patient positioning or x-ray exposure. Depending on the study, the rst three are approximately equally important, while the fourth is the cause of missed cancer in less than 10 % of the misses (Bird et al., 1992; Martin et al., 1979; Yankaskas et al., 2001). Further, the positive predictive value (PPV) of breast biopsies based on mammography (the probability that cancer is present, given a positive result on mammography) can be low, ranging from 5 % to 85 % (Elmore et al., 2003). The goal in the USA for PPV upon biopsy from a screening program is a PPV of between 25 % and 40 % (AHCPR, 1994). In Europe, the goal is a PPV of at least 34 %, with greater than 50 % desirable (de Wolf and Perry, 1996). Biopsy of benign breast disease is costly both to the patient, in terms of emotional and physical trauma, and to society, in terms of monetary costs and the use of medical resources that are often in short supply. CAD is being developed for mammography to aid radiologists in detecting cancers. It is thought that CAD will help radiologists reduce errors due to missed detections and misinterpretations of malignant lesions. There are two main types of CAD schemes being developed for mammography. The rst, which is directly applicable to screening mammography, are computer-aided detection schemes. The second, which is being developed for diagnostic mammography, are CAD schemes for classication of lesions. In the detection scheme, the mammogram is searched by the computer algorithm to identify locations of suspicious regions. These regions are then agged for the radiologist to review. In the classication schemes, an already-detected lesion is scrutinized to determine if the radiologist should recommend a biopsy. A classication scheme analyzes features of the lesion and, in its simplest

form, produces an estimate of the likelihood that the lesion is malignant. This information is then used by the radiologist when interpreting the image. Note that there are usually other imaging modalities used by radiologists as adjuncts to diagnostic mammography, such as ultrasound and magnetic-resonance imaging (MRI). The radiologist considers information from all available imaging studies and clinical information when making a biopsy recommendation. Further, classication schemes are being developed for breast ultrasound (Bader et al., 2000; Chang et al., 2000; 2005; Chen et al., 2002; 2004a; Chou et al., 2001; Drukker et al., 2002; 2003; 2004; Finette et al., 1983; Giger, 2004a; Giger et al., 1999; Horsch et al., 2001; 2002; 2004; Lefebvre et al., 2000; Sahiner et al., 2004; Sivaramakrishna et al., 2002) and for dynamic contrast-enhanced breast MRI (Alterson and Plewes, 2003; Chen et al., 2004b; Gilhuijs et al., 1998; Lean et al., 2004; Mountford et al., 2001; Setti et al., 2001; Vergnaghi et al., 2001; Wood, 2005). Research into CAD for mammography is very active. Many studies have been summarized in several reviews (Astley and Gilbert, 2004; Doi, 2007; Giger et al., 2000; Karssemeijer, 2002; Karssemeijer and Hendriks, 1997; Li et al., 1997; Mata Campos et al., 2000; Nishikawa, 2002; Sajda et al., 2002; Sampat et al., 2005; Zheng et al., 1995). In addition, a large body of non-peer reviewed research appears in the Society of Photo-Optical Instrumentation Engineers (SPIE) Medical Imaging Conference proceedings, the conference proceedings of Computers in Radiology and Surgery (CARS), and books from the International Workshop on Digital Mammography (see, e.g., Doi et al., 1996; Gale et al., 1994; Karssemeijer, 1998; Peitgen et al., 2004; Pisano and Yaffe, 2005; Yaffe, 2001). Finally, in addition to these CAD schemes, other types of CAD techniques are being developed for purposes such as predicting a womans risk of developing breast cancer based on mammographic breast density or mammographic texture of the bro-glandular tissue (Byng et al., 1996; Boone et al., 1998; Huo et al., 2002a; Li et al., 2004; Pawluczyk et al., 2003; Tahoces, et al., 1995; Wei et al., 2004; Yaffe et al., 1998; Zhou et al., 2001). 4.4.1 Computer-Aided Detection

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The goal of CAD is to assist radiologists in detecting breast cancer, principally in screening mammography, although it can be applied to diagnostic mammography as a means to nd multifocal cancers (Butler et al., 2004). CAD has the potential

Digital Mammography

to be a cost-effective alternative to independent double reading by two radiologists, in that the CAD algorithm could be used to simulate the second radiologist. Double reading has been shown to increase the cancer detection rate (Anderson et al., 1994; Anttinen et al., 1993; Brown et al., 1996; Ciatto et al., 1995; Duijm et al., 2004; Harvey et al., 2003; Kopans, 2000; Leivo et al., 1999; Taplin et al., 2000; Thurfjell et al., 1994; Warren and Duffy, 1995), but it is not widely practiced, especially in North America, because of costs and logistics. CAD has the potential to reduce the cancer-miss rate, reduce the variability among radiologists, improve the consistency of a single radiologist, and make radiologists more productive. These are important issues for improving the efcacy of screening mammography. Methodology. Most CAD schemes are designed using the paradigm shown in Figure 4.6. A digital mammogram is used as input to a CAD scheme. This can come from a full-eld digital mammography system or it can come from data acquired by digitizing a screen-lm mammogram. The rst step is to preprocess the image to segment the breast area from the non-breast area (Bick et al., 1995; Ibrahim et al., 1997; Lou et al., 2000; ndez et al., 1996; Yin et al., 1994) and to use Me image processing to emphasize lesions or certain features of lesions. For example, a bandpass lter can be used to make microcalcications more prominent (Chan et al., 1987a) or specialized nonlinear lters can be used to highlight spicules associated with malignant masses (Kegelmeyer et al., 1994; Kobatake et al., 1999; Zwiggelaar et al., 1999). Because lesions range in size, multiscale approaches are often used (Li et al., 1997; Mata Campos et al., 2000; Sajda et al., 2002; Zheng et al., 1995). After the image has been pre-processed, potential lesions are identied. The simplest means of accomplishing this is to apply grey-level thresholding, as both microcalcications and masses appear brighter than their surrounding background. Unfortunately, because the contrast of lesions in dense breast tissue can be low, simple thresholding will either produce many false detections or miss subtle lesions. Various approaches have been used to improve discrimination of lesions. These include applying grey-level thresholding to small regions in the image (Chan et al., 1990) or creating an image whose pixels represent the gradients about each pixel in the original image and applying a threshold on this gradient image (Kupinski, 2000). Once potential lesions have been identied, they are segmented from the image using different

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Figure 4.6. Concept of a computer-aided detection (CAD) system.

techniques. For example, in region growing, an initial seed pixel or area of the image is chosen and adjacent pixels are tested for a feature considered to identify those pixels as having similar properties. If the test result is positive, those pixels are added to the seed region and the process continues on the ever-expanding periphery of the region until the test provides a negative result. Region growing can be effective for segmenting microcalcications from the mammogram (Veldkamp and Karssemeijer, 1998). Because the borders of masses are often ill-dened or partially obscured by normal tissues of the breast, gradient-based methods are frequently more effective in these situations than grey-level-based methods (Kupinski, 2000). To reduce the number of false detections, features of the segmented detections are extracted from the image. Most features fall into one of the three categories: intensity based, morphology based, and texture based. These features can be extracted from the grey-scale image or from the image after it has undergone a mathematical transformation (Wei et al., 1997). There are many different features that can be used, and an optimal set has not yet been determined. If a large set of features is extracted from the images, then a subset of the features are chosen for further analysis. The subset can be determined from a stepwise analysis (Chan et al., 1995b) or using a genetic algorithm (Anastasio et al., 1998a; 1998b; Floyd et al., 1996; Kupinski et al., 1996; Sahiner et al., 1996; 1998; Zheng et al., 1999).


Once the nal feature set has been chosen, the features are merged by a statistical classier to differentiate actual lesions from false detections. Many different types of classiers can be used, such as support-vector machines (Vapnik, 1998), articial neural networks (Hecht-Nielsen, 1990; Wu et al., 1993), k-nearest neighbor (Duda et al., 2000; Veldkamp et al., 2000), and decision trees (Breiman et al., 1984; Kegelmeyer et al., 1994). Most classiers have comparable performances, although at least one study has found supportvector machines to be superior to articial neural networks (Wei et al., 2005a; 2005b). CAD algorithms are trained using a set of mammograms for which truth (i.e., the presence or absence of a cancer) is known through biopsy results or subsequent patient follow-up. Truth data are also required to evaluate the performance of a CAD algorithm. Care must be taken in training and evaluating the classier to avoid biases and to reduce the variance in the measured performance. To avoid a positive bias, cases used to train the classier are not used to test the classier. Increasing the number of testing cases can improve the performance of the classier (Zheng et al., 1997) and reduce the variance in the measured performance (Chan et al., 1999b). However, for a nite number of available cases, this reduces the number of training cases available, which reduces both accuracy and robustness of the classier. Several studies have been published addressing this issue (Chan et al., 1999b; Fukunaga and Hayes, 1989; Li and Doi, 2006a; 2006b; 2007), and also the issue of bias if the same cases are used to develop the CAD scheme (e.g., selecting features) and to train it (Kupinski and Giger, 1999; Sahiner et al., 2000). Many investigators adopt a bootstrap method to deal with these issues (Chen et al., 2002; Efron and Tibshirani, 1997; Yousef et al., 2005; 2006). By applying a threshold to the output of the classier, pairs of true-positive fraction and average number of false detections per image can be determined. By plotting these pairs, a free-response receiver operating characteristic curve can be generated (Chakraborty, 2000). For a more general discussion of receiver operating characteristic (ROC) analysis, see the beginning of Section 5 and ICRU Report 79, ROC Analysis in Medical Imaging (ICRU, 2008). In general, as the true-positive fraction increases, the false-detection rate also increases. How to balance this trade-off so as to maximize the benets of CAD to the radiologist is unknown. Studies using simulated CAD performance levels indicate that false-positive rates of 0.5 per image or fewer provide more assistance to

radiologists than CAD schemes with higher sensitivity and false-positive rates. The results of the CAD algorithm are conveyed to the radiologist by means of an image annotated to show the computer detections. For screen-lm-based CAD systems, a low-resolution version of the image is either printed on paper or shown on a monitor. The location of computerdetected masses and clustered calcications are shown using different symbols for the different lesions. For digital mammography systems, the CAD output can be annotated directly onto the radiologists display workstation. An alternative method for CAD is to train a classier using small regions of the images that either do or do not contain a lesion (El-Naqa et al., 2002; Kalman et al., 1997; Wu et al., 1992). Then an image can be analyzed by extracting small regions from the image that are centered on every pixel in the image. In this way, the full image is analyzed by the classier, with the output of the classier indicating the likelihood that the input region contains a lesion. This is most practical for calcications because they are small and the resulting input regions can be small. The larger the input region, the more difcult it is for the classier to learn the appearance of a lesion with high accuracy. Another drawback of this approach is that the classier needs to reach a very high performance level to avoid having a high false-detection rate. For a 100 mm pixel image with a breast that is 100 cm2 in area, only 1 in 5000 pixels will contain a portion of a calcication, assuming 14 calcications of size 0.4 mm. A specicity of 99 % will give rise to 50 false detections. To reduce the number of false detections, feature analysis as described above can be implemented. Alternatively, these methods can be applied to the detections initially found by another CAD scheme (Chan et al., 1995a; Sajda et al., 1996; Zhang et al., 1994). More recent research in CAD considers the combination of information from multiple images, either from a different view from the same exam, or from the same view from a previous exam. This approach more closely mimics how a radiologist reads a case, and it can improve the performance of a CAD scheme (Hadjiiski et al., 2004; Huo et al., 2001; Paquerault et al., 2002; Sun et al., 2004; Yin et al., 1991). One successful approach to developing CAD techniques is to use knowledge of image acquisition to model the appearance of the image or objects in the image. For example, information about the resolution properties of the screen-lm system, scattering properties of the breast, and the attenuation properties of lesions and breast tissue are used to predict how calcications should appear in

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Digital Mammography

the image (Highnam and Brady, 2000; Jiang et al., 1992). This can be used to reduce the rate of false detections, because, in general, calcications are compact. If the estimated thickness of a detected structure ( potential calcication) is either much greater or much smaller than the diameter of the signal, it is likely to be a false detection due to either image artifact (if much greater) or image noise (if much smaller). Performance: Laboratory. There are at least three different types of laboratory testing of CAD algorithms. The rst and simplest is to measure the performance of the CAD scheme on a set of cases. The second is to test the CAD scheme on a set of cases that includes cancers that were missed on mammography. The third is to perform an observer study in which radiologists read cases with and without the computer aid. The ultimate test of CAD is through clinical evaluation, which is described in the next section. It should be noted that comparison of different CAD systems is subject to biases due to the cases used to evaluate the scheme (Nishikawa et al., 1994) and the scoring criteria used to evaluate whether the actual lesion was detected (Kallergi et al., 1999). In general, CAD schemes for microcalcications have higher performance than CAD schemes for masses. This reects the difculty of differentiating actual masses from false detections. Microcalcications are quite distinct in a mammogram because there are few causes for a cluster of small bright objects in a mammogram other than microcalcications. On the other hand, overlapping tissue can often mimic malignant masses. Further, because masses have lower contrast than microcalcications, the borders of masses often blend into the normal background of the breast. Commercial CAD systems have up to 98 % sensitivity with fewer than 0.3 false detections per image for the detection of microcalcications, but only 85 % sensitivity with 0.5 false detections per image for the detection of breast masses. Further, mass detection schemes have difculty in detecting architectural distortions (Baker et al., 2003). While the sensitivity of these systems is comparable to that of radiologists, the false-detection rate is high. Assuming radiologists have a callback rate of 5 % to 10 %, their falsedetection rate per image (four images per examination) is between 0.0125 to 0.025, more than an order of magnitude lower than the combined falsedetection rates for masses and microcalcication for CAD. Zheng et al. (2001; 2004a; 2004b) have shown that the effectiveness of a CAD scheme, in terms of increasing radiologists performance, increases as the false-detection rate decreases.

For lm mammography, it has also been shown that CAD schemes do not always give the same result if the same lm is digitized and analyzed multiple times (Malich et al., 2000; Nishikawa et al., 1996; Taylor et al., 2003; Zheng et al., 2003). Because of mechanical variability and noise associated with the digitizer, each time a lm is digitized the resulting image, while appearing to be the same, is slightly different. These small differences can produce small differences in the features extracted from the image. As a result, potential lesions and actual lesions that are near the boundary between false and true lesions can cross that boundary. Therefore, differences in detections can be obtained upon repeated digitization and analysis. This is generally a problem for subtle lesions and false detections. Detection of non-subtle cancers is usually reproducible. The lack of reproducibility is a problem only for screen-lm based system, for which the lm needs to be digitized. It is not a problem for systems that analyze full-eld digital mammography images. There have been several studies in which CAD schemes are run on cases that contain a cancer that was missed clinically (Birdwell et al., 2001; Brem et al., 2003; Ikeda et al., 2004; Nishikawa et al., 2000; te Brake et al., 1998; Warren Burhenne et al., 2000). These cases are obtained by retrospectively analyzing previous mammograms of women who are diagnosed with breast cancer. In a fraction of these cases, the previous mammogram will have an indication that a breast cancer is present. In studies analyzing these missed-cancer cases, CAD schemes have demonstrated sensitivities between 50 % and 80 %. These studies are important because CAD will be benecial to radiologists only if (a) it can detect cancers that a radiologist misses and (b) the radiologist will act appropriately when shown the CAD output. These studies show that at least the rst condition is satised. To test the second condition for CAD to be benecial, observer studies are conducted in which radiologists (observers) are shown a set of cases under two different reading conditions, one without using CAD and one using CAD (Metz, 1989). There have been only two published observer studies using CAD: one by Chan et al. (1990) for the detection of microcalcications and the other by Kegelmeyer et al. (1994) for the detection of spiculated lesions. Chan et al. measured an improvement in performance as determined by the area under the ROC curve (see beginning of Section 5), which increased from 0.94 to 0.97 (P 0.001) when the CAD scheme was used. Kegelmeyer et al. did not use ROC analysis. They found that the radiologists sensitivity was 80.6 % with a specicity of

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95.5 % reading without aid, and a sensitivity of 90.3 % with a specicity of 97.0 % when using the computer aid. The 9.7 % increase in sensitivity was statistically signicant (P 0.005), and the 1.5 % increase in specicity was not (P 0.395). These studies indicate that there is potential for CAD to improve radiologists performance clinically when reading screening mammograms. Performance: Clinical. At the time of this writing, there have been 12 clinical studies published on the clinical benets of CAD (Birdwell et al., 2005; Cupples et al., 2005; Dean and Ilvento, 2006; Fenton et al., 2007; Freer and Ulissey, 2001; Georgian-Smith et al., 2007; Gromet, 2008; Gur et al., 2004; Helvie et al., 2004; Khoo et al., 2005; Ko et al., 2006; Morton et al., 2006). In all but one of the studies, CAD was used to simulate a second reader in conjunction with a single radiologist. In the study by Khoo et al. (2005), CAD was used in a different manner, i.e., in the context of double reading. The 11 other studies can be divided into two groups based on the methodology employed. Four of the studies used a longitudinal design in which the cancer detection rates and the recall rates were compared between periods of time before and after implementation of CAD. The other 7 studies were cross-sectional in design. In those, the radiologist read the mammograms and recorded an interpretation. Then the CAD output was presented to the radiologist who could then choose to modify the interpretation. The number of extra cancers detected because CAD was used and the increase in recall rate when CAD was used were measured. Longitudinal studies are retrospective while cross-sectional studies are prospective. While both designs have been used, they are not equivalent. The goal of CAD is to reduce the cancer-miss rate. The longitudinal method is not a valid method for measuring the clinical benets of CAD because it does not measure the miss rate. The cross-sectional method is a direct measure of the effect of CAD in reducing the miss rate. The cross-sectional method, however, can contain signicant biases. Radiologists might be less vigilant when reading without CAD because the only interpretation is the nal one, which comes after reviewing the CAD output. This would be a positive bias in favor of CAD (Gur et al., 2004). In contrast, radiologists might read more vigilantly when reading without the computer because they do not want to have reported that they miss many cancers. This is a negative bias in evaluating the performance of CAD (Birdwell et al., 2005). It is not possible to know which, if any, bias is present in a study.

The cross-sectional studies indicate an approximately 10 % increase in sensitivity when CAD is used. This increase needs to be considered alongside the increase in recall rate when CAD is used. The cross-sectional studies indicate an approximately 13 % increase in recall rate. One approach to understand this trade-off is to compare these rates to independent double reading, as CAD is considered by some as a means to implement double reading with a single radiologist. Gromet (2008) found that a single radiologist using CAD had comparable sensitivity and recall rate to two radiologists practicing independent double reading (90.4 % versus 88.0 % and 10.6 % versus 11.9 %, respectively).
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CAD for Characterization of Lesions Methodology. Methods used in CAD schemes for characterization of suspicious abnormalities are not unlike those used in CAD schemes for detection. The difference is that for characterization of lesions only the small region of the image that contains the lesion is analyzed. Thus, the preprocessing step is applied only to the lesion region or eliminated altogether. The location of the lesion can be determined either manually or by a computer-aided detection scheme. Once a lesion position is known, it can be segmented. Techniques used in computer-aided detection schemes for segmentation can be used here. Features are extracted from the image, and the features can be the same as the features used in detection schemes or they can be different. In detection schemes, the goal is to distinguish between an actual lesion and false detections. In classication schemes, the goal is to distinguish between a malignant lesion and a benign lesion. Therefore, features that can be useful for detection might not be useful for classication and vice versa. For example, in calcication detection, image artifacts are often very bright compared to actual calcications, so that a feature that measures the contrast of the calcication candidate as a function of its size can be a useful feature for detection. But the contrasts of actual benign and actual malignant calcications are similar, so contrast as a function of size is not a useful feature for classication. Classiers that are useful for merging detection features can be used to merge classication features, even if the feature sets are different. An alternative approach that has been developed for classication relies on features that describe the lesion, as identied by the radiologist. These are then analyzed by a computer algorithm to estimate the likelihood that the lesion is malignant (Baker

Digital Mammography

et al., 1995; Getty et al., 1988; Lo et al., 1995). With the existence of the Breast Imaging Reporting and Data System (BI-RADS) lexicon (ACR, 1995; 2003), this approach is clinically practical and potentially very powerful. Unfortunately, there can be wide disagreement among radiologists in describing the same lesion (Baker et al., 1996; Berg et al., 2002), reducing the effectiveness of this approach (Lo et al., 2002). Regardless of the specics of implementation, CAD classiers are trained using images of lesions drawn from a reference library containing hundreds of lesions with known pathology. The biggest difference between CAD classication and detection techniques is in the display of the CAD output. Unlike detection CAD, in which the output can be annotated onto the image, the classication CAD provides a number that is an estimate of the likelihood of malignancy. This can be simply displayed in a conspicuous location on a monitor. However, more sophisticated displays have been developed (Giger, 2004b), in which, in addition to displaying the likelihood of malignancy, small thumbnail images of lesions (retrieved from an archival image library) displaying similar features to the one in question and their status (malignant or benign) can be displayed on the screen. Performance: Laboratory. To date, laboratory testing has included measuring performance

on a set of cases and observer studies. Several researchers have shown that on a set of cases containing malignant and benign lesions (all biopsy proven) that the CAD scheme has comparable or higher performance than radiologists for both microcalcications and masses, and further that when radiologists use the CAD they have higher performance in distinguishing benign and malignant lesions (Baker et al., 1995; Chan et al., 1999a; Getty et al., 1988; Huo et al., 1998; 2002b; Jiang et al., 1996; 1999; Leichter et al., 2000; Lo et al., 1995; Sklansky et al., 2000). The reason that the computer can have higher performance is that it is better able than the human observer to assimilate the many features of the lesion to form the correct diagnosis. Wu et al. (1993) showed that an articial neural network, trained and tested using features of the lesions extracted by the radiologist, could more accurately predict which lesions were malignant than the radiologist who extracted the features. Further, Jiang et al. (1999) have shown that the computer analyzing screening mammograms digitized at 100 mm pixel size could outperform radiologists who read, in addition to the screening mammograms, magnication-view mammograms, which can more accurately depict the number, morphology, and contrast of the microcalcications. These studies indicate that there are potentially large gains from using CAD clinically. Currently, however, there are no commercial CAD systems for classication of lesions.

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Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


5. Technical Aspects of Image Quality in Mammography

It is widely recognized that high-quality images are imperative for the reliable detection and accurate characterization of subtle lesions in the breast with mammography. The quality of the images depends critically on the design and performance of the x-ray unit and image receptor, and on how that equipment is used to acquire and process the mammogram. In addition, the type of display and the conditions under which the image is viewed have an important effect on the ability of the radiologist to extract the information recorded in the mammogram (ICRU, 2008; Kundel and Revesz, 1976). In general, the phrase mammographic image quality can be considered to mean the ease with which radiologically signicant details can be perceived in an image. In turn, high mammographic image quality should contribute to high performance in detecting and diagnosing breast cancer. There is, however, no well-dened standard for specifying mammographic image quality. The relationship between physical properties of the radiographic image (such as contrast, resolution, and noise) and the ability of the observer to properly detect and interpret relevant image features is not well understood (ICRU, 2003; Vyborny and Schmidt, 1994). 5.1 ROC Analysis negative (FN). The true-positive fraction or test sensitivity is the sum of all of the TP ndings divided by P, while the specicity or true-negative fraction (TNF) is the sum of all the TN ndings divided by N. The TNF is equal to (1 2 FPF), where FPF is the sum of the FP ndings divided by P. By varying the threshold of the test that attempts to discriminate between positive and negative, the sensitivity will increase at the cost of loss in specicity and vice versa. The ROC curve is simply a graph of sensitivity versus FPF or (1 2 specicity). A given test can be operated at any point on the ROC curve by adjusting the discrimination threshold; a better test will have a curve that is higher. Because curves can cross, a common metric for the quality of a test is the area, often abbreviated as Az, under the ROC curve. For a complete discussion, refer to ICRU Report 79, ROC Analysis in Medical Imaging (ICRU, 2008). ROC testing can be used to assess the overall performance of a radiologist or a cohort of radiologists in combination with a particular imaging system for detecting or diagnosing breast cancer in terms of sensitivity at varying levels of specicity. This creates a measure that is based on perception of information in the mammogram and is essentially independent of the level of conservatism of the radiologist in calling abnormal ndings. Unfortunately, ROC studies are complex, timeconsuming experiments, requiring large image databases with known truth data regarding disease. They require many image readings by many observers, and are therefore often not practical for routine measurement of image quality. Nevertheless, in the large DMIST study to compare the performance of digital mammography versus screen-lm mammography for cancer detection (Pisano and Yaffe, 2005), ROC analysis was employed. In that study it was seen that the area under the ROC curve was signicantly higher for digital mammography than for screen-lm mammography, both for women under 50 and for those with dense breasts. Logically, mammographic image quality should be related to certain image attributes that can be

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Currently, probably the most effective tool for inferring the accuracy of an imaging system is the receiver operating characteristic (ROC) curve methodology (ICRU, 1995; 2003; 2008; Metz, 1979), applied retrospectively to clinical images for which the true disease state is known. In ROC analysis, a test that produces a binary output or test result (typically positive for disease or negative for disease) is applied to a number of cases in which the true disease state is known, say P cases in which disease is present (the positive cases) and N cases where it is not (the negative cases). Each time the test is performed, the result will take on one of the four values: true positive (TP), true negative (TN), false positive (FP), or false

# International Commission on Radiation Units and Measurements 2009


described technically, such as spatial resolution, contrast, image noise, and signal-to-noise ratio (SNR) and the absence of artifacts. It is accepted that these are important parameters that will affect the ability to detect or characterize microcalcications or to visualize ne brillar structures radiating from a mass or the presence of architectural distortion. The exact relationship, however, is not yet well understood, i.e., it is still not known how to dene what constitutes optimal or necessary quality for diagnostic accuracy in terms of technical parameters and/or the appropriate weights that each of these parameters should be given. There are trade-offs involved in the selection of most parameters (e.g., dose and noise are inversely related to one another). Furthermore, the optimum choice of technical parameters in forming the image to achieve high mammographic quality is likely to be task dependent. What will be optimal for the visualization of small, high-contrast objects such as microcalcications might not be ideal for the characterization of ill-dened low-contrast masses. At present, about the best that can be done is to attempt to correlate differences in ROC performance with differences in the technical aspects of image acquisition and display. This issue is the subject of continuing research (Bencomo et al., 1982; Bunch et al., 1977; Chan et al., 1987b; Metz, 2000). Nevertheless, there is a strong correlation between radiologists rejection of mammograms as having inadequate quality and low measured values of resolution, contrast, and SNR, or the excessive prevalence of artifacts. In this section, the descriptors of technical image quality, which can be quantied objectively, are reviewed and their dependences on the many variables of image acquisition and display in screenlm and digital mammography are discussed. The term technical image quality is used to include those factors that are amenable to measurement in the imaging process. The major parameters describing image quality are: radiographic contrast, spatial resolution (blur), noise (mottle, or, probably of greater relevance, the signal-to-noise characteristics), and the presence of artifacts. These must be considered in relation to the dose to the breast required to produce the mammogram. The technical factors that inuence these parameters are listed in Table 5.1 (Haus and Jaskulski, 1997; NCRP, 1986). Image quality, as used here, refers to the aggregate effect of these elements on the usefulness of the mammographic image. Inevitably, there are trade-offs among the many components involved (Haus et al., 1976; Hendrick and Berns, 1999). Many of the factors in image acquisition and display can be controlled and optimized, so that

mammograms having good image quality can be obtained at reasonable absorbed dose to the patient. Using the outline in Table 5.1, the factors affecting technical image quality will be reviewed for screen/lm and digital mammography image receptors, with emphasis on those that can be controlled by the user. 5.1.1 Sensitivity

Image receptors used for screen-lm or digital mammography can be characterized by their sensitivity. All receptors involve the interaction of x-ray quanta. The efciency of this process is dependent on the x-ray energy, E, and is described by the x-ray quantum-detection efciency, h(E). The energy of the quantum is then totally or partially absorbed locally and converted into a secondary signal in the form of light quanta or charge. This process is described by the conversion factor g1(E) of the receptor. Depending on the complexity of the receptor, there can be other factors, g2, . . . , gn, (e.g., the escape of light from a phosphor) that determine the measured signal, L. In general,   5:1 L f Ninc hE P gi ;

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where Ninc is the number of x-ray quanta incident on the receptor. In a screen-lm image receptor, the measured signal is the optical density (OD) of the lm image. The OD is dependent, in a non-linear fashion (see Figure 3.8), on the exposure that is incident on the intensifying screen. A specic exposure is required to achieve a target OD. A simple index of sensitivity or speed of the screen-lm-processing combination is given by the reciprocal of that exposure. The speed is determined by several factors including the quantum-detection efciency of the screen, the conversion factor for the screen, the sensitivity of the lm emulsion, and several factors associated with lm processing. In lm imaging, it is desirable to operate at a xed target OD. To maintain xed OD, any changes in a factor that affects OD must be compensated by changes in another factor. For example, if the sensitivity of the image receptor varies, this must be compensated by a change in the exposure. For digital systems, the measured signal is simply a numerical value, ranging from 0 to 2n 1, where n is the number of bits of digitization. The functional form in Eq. (5.1) is either linear or logarithmic depending on the technology used. For such systems, sensitivity can be dened in terms of the reciprocal of the amount of radiation required to

Technical Aspects of Image Quality in Mammography

Table 5.1. Factors affecting image quality in mammography FACTOR RADIOGRAPHIC CONTRAST Radiation contrast tissue properties (absorption differences) x-ray spectrum (machine parameters) Scattered radiation beam collimation compression air gap grid lm emulsion type processing Film-Screen Systems Digital Systems

thickness density atomic number target (Mo, Rh, W) lter material (Mo, Rh, Al) kilovoltage

Film gradient

chemistry replenishment rate temperature time

agitation optical density fog

Digital contrast

detector response hard-copy display

soft-copy display

look-up table enhancements

storage safelight light leaks linearity number of bits dynamic range lm granularity base plus fog maximum OD number of bits printing dynamic range maximum brightness minimum brightness noise phosphor persistence ambient light characteristic curve of monitor number of bits displayed shape (linear / nonlinear) window / level setting edge sharpening adaptive contrast thickness compensation



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RESOLUTION Motion blurring Geometric blurring

Screen-lm blurring

Digital-detector blurring

breast compression exposure time focal-spot size focal-spot-object distance object-image-receptor distance phosphor thickness phosphor-particle size light-absorbing dyes and pigments screen-lm contact phosphor thickness phosphor structure optical coupling detector-element aperture detector-element pitch signal-transfer efciency




Table 5.1. Continued FACTOR IMAGE NOISE Quantum mottle Film-Screen Systems Digital Systems

X-ray-to-light uctuations (Swank noise) Screen-lm

Digital ARTIFACTS Machine related

dose phosphor absorption phosphor-conversion efciency light diffusion radiation quality lm speed lm contrast signal-coupling efciency phosphor type x-ray spectrum screen structure lm granularity lm processing electronic noise digitization noise (number of bits) lter deterioration grid streaks breast-support structure foreign matter in beam handling





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crimp marks nger marks scratches static light exposure darkroom fog streaks spots scratches dirt stains at-elding stitching scanning artifacts dead pixels persistence (lag and ghosting) raster lines (monitor or laser printer) non-uniform display brightness or focus


produce a desired digital value from the receptor. Because the image can easily be scaled, this denition is of limited value. Nevertheless, when monitored in a quality-control program, unexpected changes in sensitivity can be indicative of technical problems with the system. 5.2 Noise

Radiographic noise or mottle is the unwanted random variation in signal in a radiograph that has been given a uniform x-ray exposure. For screen-lm mammography, major sources of radiographic noise include: (1) quantum noise, (2) screen-structure mottle, (3) lm grain, (4) lmprocessing artifacts, and (5) x-ray-to-light

conversion noise (Barnes, 1982; Swank, 1973). Depending on the type of digital mammography system and the viewing method, it is possible to eliminate screen-structure noise and lm grain noise; however, additional noise sources can result from at-elding1 and detector-gain variations, and from electronic noise of the detectors and the analog-to-digital conversion system. One can never acquire the same image twice; each image is subject to random uctuations. One

Flat-elding is the process of imaging an object that provides nominally spatially uniform attenuation, recording the spatial variation in signal from the image receptor, and deriving a point-to-point correction to be applied to subsequent images produced with the system in order to compensate for this variation.

Technical Aspects of Image Quality in Mammography

unavoidable source of such noise is the random uctuations in the primary x-ray uence rate and the probabilistic nature of the x-ray interactions with the detector. Furthermore, each stage in the imaging process that involves the production of new quanta, such as the production of visible-light photons or the promotion of electrons into the conduction bands of semi-conductors, adds a statistical aspect to the process, and therefore constitutes another source of noise. A variety of additional sources of noise, such as electronic noise and lm granularity, will also degrade the quality of the nal image. These random uctuations place fundamental limits on the reliability with which one can distinguish the weakest signals of interest from the background. From the point of view of clinicians, an image with excessive quantum mottle appears grainy, and clinically signicant lesions, especially microcalcications, can be obscured, or the random noise pattern can mimic the presence of non-existent lesions. 5.2.1 Standard Deviation

Figure 5.1. Typical Wiener (noise-power) mammography screen-lm system.



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The simplest characterization of noise is in terms of the standard deviation of the number of x-ray quanta recorded in a given area of the image receptor or the standard deviation in image signal (OD or digital-image value) over a given area of the image, for which the mean x-ray uence is expected to be constant. Quantum noise is caused by the random spatial variation of the x-ray quanta absorbed in the image receptor. Its fundamental characteristic is described by the Poisson distribution, so that its absolute magnitude in terms of standard deviation  1=2 . of the measured x-ray signal, N, is related to N is the average number of x rays in a Here, N dened area that are used to form the image.  1=2 and, Relative to the signal, its effect scales as N therefore, the apparent effect of quantum noise is reduced as more x rays are used to form the image. 5.2.2 Wiener Spectrum

The standard deviation says nothing about the spatial characteristics of the noise. This is better described by the Wiener spectrum (WS) of the image noise (see Figure 5.1), also referred to as the noise-power spectrum (Bendat and Piersol, 1971; 1986; Dainty and Shaw, 1974; Rossmann, 1963; Schade, 1952). The WS is plotted to show how the variance of the image signal is distributed over spatial frequency. The measurement of noise in projection radiography can be traced back to the work of Sturm and Morgan (1949), while in later work by multiple

researchers (Doerner, 1962; Doi, 1969; Lubberts, 1968; Rossmann, 1962; 1964; Vyborny et al., 1982) the ideas of spectral analysis were introduced. Scanning microdensitometers were used to convert the spatial pattern of lm opacity into digital data. The application of spectral techniques to radiographic lm has been particularly fruitful because lm, under appropriate conditions, approximately satises the assumptions of stationarity and linearity upon which the theory of signal detection for linear systems is based. A system is said to be stationary if its response to a signal is independent of position relative to the device. A system is said to be linear if a change in the incident signal results in a proportionate change in expected value of the record of that signal. For the purposes of Wiener spectra, the condition of stationarity is not strictly necessary, but can be replaced by the weaker condition of wide-sense stationarity. A system is said to be wide-sense stationary if its second-order statistics, e.g., its autocorrelation function, are independent of position relative to the detector. For small variations relative to a uniform x-ray exposure, radiographic lms approximately satisfy both conditions. In terms of stationarity in particular, the response of appropriately manufactured lm does not depend upon position unless one considers either length scales so small that the discrete nature of the silver-halide crystals becomes apparent or length scales as large as the lm sheet itself so that variation in the emulsion thickness becomes apparent. For small signals, the lm response can be linearized using the H&D curve. 5.2.3 Dependence of Noise on Detector Characteristics

To be useful, an x-ray quantum must not only be incident on the detector, but also interact with it.


The quantum noise is determined by the uence of incident x rays and also by the detectors quantumdetection efciency, h. The quantum-detection efciency is related to the attenuation coefcient and thickness of the x-ray absorbing material that makes up the sensitive volume of the detector. If the detector employs a phosphor as the x-ray absorber, the screen must be made relatively thin to avoid lateral diffusion of light that would degrade spatial resolution (Rossmann 1962; Sturm and Morgan, 1949). Noise in Screen-Film Mammography. As discussed in Section 5.1 for imaging with lm, it is required to produce a target OD, so a predened amount of light from the screen must expose the lm. The desirability of maintaining a relatively low quantum-noise level in the image mandates that an adequate number of x-ray quanta be used by the detector, and this requires that the conversion efciency of the screen material and the sensitivity of the lm not be excessively high. With very high conversion efciency, an image with proper OD could be produced at low dose, but with an inadequate number of quanta contributing to the image. Similarly, lm granularity and screenstructure noise generally increase as more sensitive lms or screens are used, so that again speed of these components must be limited to maintain high image quality. For current high-quality mammographic imaging employing an anti-scatter grid, with lms exposed to a mean OD of at least 1.75, the mean glandular dose to a 5 cm thick compressed breast consisting of 50 % broglandular and 50 % adipose tissue is in the range of 1.5 mGy to 2 mGy (Conway et al., 1992; Young, 2002). Figure 5.2 shows images obtained with different numbers of x-ray quanta. Such results could occur, for example, with the use of screen-lm systems of

different speed. For faster (more sensitive) systems obtained by using screens with increased conversion efciency, faster lms, or more aggressive processing, fewer x rays must be absorbed by the screen to achieve a given OD. When fewer x rays are used, the uctuation in the image (relative to the useful signal) increases, causing the image to appear noisier (Rossmann, 1963; 1965). Noise in Digital Mammography. In digital mammography, lm granularity of the receptor is eliminated; however, there can be variations in sensitivity of the receptor, which would cause the image to have structure that is unrelated to the tissues in the breast. As long as the system design ensures that these variations are temporally stable, this xed-pattern noise can be eliminated by at-elding, i.e., by imaging a uniform eld of x rays and using the recorded image as a correction mask to make the image uniform (Critten et al., 1996). If the at-elding is not performed properly, residual noise can result. In addition, there can be noise associated with the electronic circuitry that amplies and digitizes the detector signal. Finally, there will be some level of granularity associated with either the soft-copy display device or with the lm used to print the hard-copy digital images. For a digital system to perform well, it must be designed to minimize these non-quantum-noise sources such that the SNR is determined by the level of radiation used. Digital mammography presents greater exibility compared to screen-lm mammography in selecting exposure factors, particularly in the strategy for use of automatic exposure control. In lm mammography, great care must be taken in obtaining an exposure that achieves a target OD on the processed lm, because both the image brightness and local display gradient are determined by the point on the lms H&D curve to which a given location in the image is exposed. This can result in either more or less radiation being used compared to that required to attain a desirable image signal-to-noise level. In digital mammography, because image brightness and display contrast can be independently controlled at the display workstation, the primary function of the AEC should be to achieve the appropriate SNR to allow perception of lesions.

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Figure 5.2. Illustration of noise associated with the number of x-ray quanta used to produce an image. Relative exposures are indicated.


Radiographic contrast refers to the magnitude of the signal difference between the structure of interest and its surroundings in the displayed image.

Technical Aspects of Image Quality in Mammography

Radiographic contrast is inuenced by two factors: radiation contrast and display contrast. In Eq. , where (3.1), radiation contrast is dened as DN/N DN is the difference in x-ray exposure to the image receptor transmitted through one part of the breast is the mean of and through an adjacent part, and N the two values. For lm-based mammography and for printed digital images, the overall radiographic contrast is quantied as the difference in OD, DOD, between two areas on the processed lm, while for soft-copy digital imaging it can be quantied in terms of the relative brightness difference between the corresponding areas in an image displayed on a monitor. 5.3.1 Radiation Contrast

Radiation contrast is especially important in mammography because of the subtle differences in tissue density between normal and pathologic structures of the breast, and because of the importance of detecting minute details such as microcalcications and the structural characteristics of the margins of soft-tissue masses. Radiation contrast is caused by differences in the x-ray attenuation properties of the lesion and those of the surrounding tissue (see Figure 3.2). These differences depend on the thickness of the lesion and that of the compressed breast, and the mass density and effective atomic number of the lesion and normal tissue. These differences and therefore the contrast also depend on the x-ray energy spectrum used for producing the mammogram. This is often referred to as the radiation quality and characterized by the half-value layer (HVL) of the beam (see Section 6.2.4). The x-ray spectrum is determined by the tube target material, kV setting, and ltration (either inherent in the tube or added at its exit port). The radiation contrast of masses and calcications falls as the energy of the x rays increases (see Figure 3.3). Contrast is also dependent upon the amount of scattered radiation recorded by the image receptor, and this is affected by the beam limitation (collimation), compression, and the antiscatter grid. X-Ray Energy Spectrum Target Material. A practical source of monoenergetic x rays is not available for mammography; rather, a spectrum from a metallic target that has been bombarded by energetic electrons is used. The spectrum should contain quanta of energies that represent a reasonable compromise between absorbed dose (high at low energies, becoming lower as energy increases) and image contrast (low at high energies, becoming higher as energy

decreases). The shape of the spectrum is controlled by adjustment of the kilovoltage, choice of the target material, and the type and thickness of lter(s) placed between the x-ray tube and the breast. Based on models of the imaging problem in mammography, it has been suggested that the optimum energy for imaging lies between 18 keV and 23 keV, depending on the thickness and composition of the breast (Beaman and Lillicrap, 1982). It has been found that for the breast of typical thickness and composition, the characteristic x rays from molybdenum at 17.4 keV and 19.6 keV provide good imaging performance. For this reason, molybdenum-target x-ray tubes are used on the vast majority of mammography machines. Most mammography tubes use beryllium exit windows between the evacuated tube and the atmosphere, as glass or other materials used as windows in general-purpose tubes would provide excessive attenuation of the energies useful for mammography. Figure 5.3 compares tungsten- and molybdenum-target spectra for typical berylliumwindow x-ray tubes. This tungsten spectrum is dominated by bremsstrahlung radiation, and there are no prominent characteristic emissions from W (K-shell characteristic x rays at 59 keV and 67 keV) in the spectrum because the kilovoltage used for mammography is much below the K edge of W. However, intense emission of L-shell x rays from tungsten are emitted, and it is essential that these be ltered from the beam before it is incident upon the breast, as extremely high doses to the skin would result from this radiation without useful contribution to the mammogram. For thicker, denser breasts, few low-energy photons are able to pass through the breast, and because of the greater ltering action of a thick

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Figure 5.3. Representative tungsten- and molybdenum-target spectra for mammography. The spectrum from the W target is ltered with 50 mm of Rh. The K lines in the Mo (30 mm Mo lter) spectrum are seen at 17.5 keV and 19.5 keV. Courtesy Dr. John Boone.


dense breastabsorption differences among structures become smaller in the resulting harder x-ray beam. Therefore, radiation contrast is not as high as with average-sized and fatty breasts. In addition, as a dose-saving measure, higher energy incident x-ray beams are typically used to image these breasts. Although the effective energy can be adjusted by varying kilovoltage, the effect on the spectrum is somewhat limited because of the dominance of the xed-energy characteristic x rays from the target. Because its spectrum is not dominated by characteristic x rays, tungsten can provide considerable exibility in controlling the beam energy through a choice of kilovoltage and beam ltration. A tungsten target provides greater efciency than molybdenum in producing beams at higher energy. Another way of producing a more penetrating x-ray spectrum than that obtained with molybdenum is to employ a rhodium target. Rhodium has characteristic emissions at 20.1 keV and 22.8 keV. Typical x-ray spectra from both molybdenum- and rhodium-target mammography tubes are shown in Figure 5.4. Filtration of the X-ray Beam. In general radiography, lters made of aluminum or copper are used to provide selective removal of low x-ray energies from the beam before it is incident upon the patient. In mammography, particularly when a molybdenumtarget x-ray tube is employed, a molybdenum lter 25 mm to 35 mm thick is generally used. This lter attenuates x rays both at low energies and those above its own K-absorption edge, allowing the molybdenum characteristic x rays from the target to pass through the lter with relatively high efciency. As illustrated in Figure 5.5, this K-edge ltration results in a spectrum enriched with x-ray energies in the range of 17 keV to 20 keV.

Figure 5.5. Effect of a Mo K-edge lter (30 mm) on a mammography spectrum from a Mo target. The ltered spectum has been scaled upward for clarity.

Although this spectrum is relatively well-suited for imaging the breast of average attenuation, slightly higher energies are desirable for imaging dense and/or thicker breasts. Because the molybdenum-target spectrum is so heavily inuenced by the characteristic x rays, an increase in the kilovoltage does not substantially change the shape of the spectrum. As discussed in the previous section, this motivates the use of alternative target materials. To further optimize imaging performance, it is desirable to tune the effective spectral energy by using these target materials in combination with appropriate K-edge lters (Desponds et al., 1991; Jennings et al., 1993). Rhodium has a K-shell absorption edge at 23.2 keV, so a rhodium lter will preferentially pass energies between 20 keV and 23.2 keV. Used with a molybdenum target at the same kilovoltage (see Figure 5.6) or in combination with an increase in kilovoltage, this will give a more penetrating spectrum than that obtained with the Mo/Mo combination. This can be helpful in imaging thick breasts (greater than 5 cm or 6 cm) of fatty tissue or average composition. If it is desired to get an even more penetrating beam than available with Mo/Rh,

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Figure 5.4. Comparison of spectra from a molybdenum target (30 mm Mo lter) at 26 kV and a rhodium target (25 mm Rh lter) at 30 kV. Courtesy Dr. John Boone.

Figure 5.6. Effects of Rh lter (25 mm) and Mo lter (30 mm) on a Mo-target spectrum at 26 kV. Courtesy, Dr. John Boone.


Technical Aspects of Image Quality in Mammography

a rhodium target can be used in combination with a rhodium lter (see Figure 5.4). The Rh/Rh combination is most effective with very dense, difcult-to-penetrate breasts, providing some dose reduction, while preserving as much radiation contrast as possible in these difcult-to-image breasts (Beaman and Lillicrap, 1982). It is also possible to provide a suitable spectrum for imaging the dense breast with a tungstentarget tube and various lters such as rhodium (see Figure 5.3). While this does not provide the quasi-monoenergetic x rays available with the Mo and Rh targets, careful choice of kilovoltage and lter material and thickness can yield excellent results in terms of contrast and dose. Recently, an Ag lter (K edge at 25.5 keV) has been introduced for use with a W-target tube, primarily for digital mammography. The potential value of such a combination in providing an optimum combination of penetration (i.e., dose efciency) and radiation contrast for mammography was suggested by Beaman and Lillicrap (1982). Voltage Settings. For screen-lm mammography, kV settings between 22 and 32 are typically used, depending on breast tissue thickness and composition, the x-ray target and lter materials, and exposure-time constraints. With a breast of average compressed thickness (5 cm) and composition (50 % broglandular/50 % fat), a typical setting might be Mo/Mo, 26 kV. Hendrick (1999) has shown that increasing kV settings between 24 kV and 32 kV, at comparable optical densities, causes a slight decrease in lesion detection; however, for dense and thick breasts, for which exposure time might otherwise be excessive, a modest increase in kilovoltage is probably worthwhile to avoid motion blur or very high dose while maintaining an appropriately high OD to achieve good contrast. Generally, the kilovoltage is increased when shifting the target/lter combination to a more-penetrating beam condition. Contrast in Digital Mammography. In screen-lm mammography, image contrast is typically a limiting factor because of the xed gradient of the lm characteristic curve and the fact that gradient diminishes outside of a fairly narrow exposure range. For this reason, it is important to employ a low-energy x-ray beam to achieve acceptable radiation contrast. However, for digital mammography systems, the large dynamic range of the detector and the ability to adjust display contrast allows slightly higher energy x-ray beams of inherently lower radiation contrast to be used compared to screen-lm mammography. Except for small breasts, tungsten or rhodium targets with various

lters selected according to breast composition and thickness appear to provide a better compromise between SNR and dose than is obtained using molybdenum-target tubes (Fahrig and Yaffe, 1994; Venkatakrishnan et al., 1999). Compression. There are several reasons for applying rm (but not necessarily painful) compression to the breast during the examination. Compression causes the different tissues to be spread out, minimizing superposition from different planes and thereby improving conspicuity of structures. It also enhances the tissue distortion caused by the radiating brous structures for some cancers. As will be discussed later, scattered radiation can degrade contrast in the mammogram. The use of compression decreases the ratio of scattered to directly transmitted radiation reaching the image receptor. In a study using phantoms, Barnes and Brezovich (1978) showed that reducing the thickness from 6 cm to 3 cm by compression reduced the scatter-to-primary ratio (SPR) from 0.8 to 0.4. Compression also decreases the distance from structures within the breast to the image receptor (i.e., the object-image distance, OID) and in this way reduces geometric unsharpness. The compressed breast provides lower overall attenuation to the incident x-ray beam, allowing absorbed dose to be reduced. The compressed breast also provides more uniform attenuation over the image. This reduces the exposure range that must be recorded by the imaging system, allowing more exibility in choice of lms to be used. Finally, compression provides a clamping action, which reduces anatomical motion during the exposure that can contribute to image unsharpness. The benets of compression are similar for both screen-lm and digital mammography. It is important that the compression plate allows the breast to be compressed to become as uniform in thickness as is reasonably achievable. The edge of the compression plate at the chest wall should be straight and aligned with both the focal spot and image receptor to maximize the amount of breast tissue that is included in the image (see Figure 3.5). Various mechanisms, which include tilting plates and spring devices, have been developed to facilitate breast compression. Scattered Radiation. In soft tissue, even at the low energies used in mammography, scattering is an important mechanism by which x rays interact with breast tissue. Scattered x rays that escape the breast and are recorded by the image receptor reduce image contrast. The amount of scattered radiation recorded compared to that of

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the useful, directly transmitted ( primary) x-ray intensity is characterized by the SPR. It is not unusual for the SPR to be greater than 1.0, i.e., more than 50 % of the total radiation incident on the image receptor has experienced a scattering interaction within the breast. For screen-lm systems, scattered x rays recorded by the image receptor have the following effects: (1) to reduce the value of radiation contrast; (2) to use up some of the available recording range or latitude of the lm by recording essentially useless information; and (3) to reduce its SNR, which is a measure of the information content of the mammogram. The effect of recording scattered radiation can be considered as creating a quasi-uniform haze on the image. This causes the radiation contrast to be reduced to DN Nb Nlesion Cscat  Nb Nlesion 1 SPR=2 N Cns ; 1 SPR


where Cns is the contrast in the absence of scattered radiation, given by Eq. (3.4), and SPR is the scatter-to-primary ratio at the location of interest in the image. In digital mammography, the same factors affecting radiation contrast apply; however, the effect of scattered radiation on the nal radiographic contrast is somewhat different. Because x rays can scatter multiple times within the breast, their spatial distribution is diffuse [i.e., mainly affecting the low-spatial-frequency part of the modulationtransfer function (MTF); see Section 7.4.4 and ICRU (1995)] and they produce a general increase in average background-signal value. This unwanted signal can be locally removed by simple subtraction of the broad-area local mean. For this reason, in digital systems, much of the contrast can be recovered by viewer adjustment of the computer image display. Similarly, the system can be designed such that the dynamic range of the image receptor is very large, so that recording of scattered radiation will not be a limiting factor. Under these conditions, only the contribution by random quantum noise should be of any importance.

In the study by Barnes and Brezovich (1978) mentioned above, the use of a mammographic grid further reduced the SPR to 0.14. The contrast-improvement factor is the ratio of the radiation contrast obtained with a grid to that without a grid in place. In mammography, this can range from about 1.05 to 1.9 (Rezentes et al., 1999). The majority of grids used for mammography consist of lead strips separated by spacers of radiolucent material (the interspace) such as carbon ber, paper, or wood. Moving-type grids, which blur the grid lines, are preferred for mammography. While grids are effective in preventing much of the scattered radiation from reaching the image receptor, they are inefcient for several reasons: part of the primary beam strikes the grid septa and is lost, and some primary quanta are absorbed in the grid interspace material. More recently, focused rhombic cellular-structure air-core grids have been introduced (Rezentes et al., 1999). These grids offer the potential of improved image contrast and transmission efciency compared with conventional grids. Because of the losses of primary quanta and the need to compensate for the removal of scattered quanta (to maintain lm OD and gradient), grids designed for mammography generally require exposures that are approximately 2 to 2.5 times higher than those used for non-grid techniques. The ratio between the exposures required with a grid and that required without a grid is known as the Bucky factor. The benet, in terms of improved image quality, of using a grid in screen-lm mammography is considered to be so large that grids are used almost universally for non-magnication views. Air Gap. Air gaps have been used in several areas of radiography as an alternative to a grid. The principle of operation is simple. Primary x rays diverge within a narrow cone from the location of the x-ray focal spot, while scattered x rays diverge over a much broader range of angles from locations within the patient. Therefore, a gap placed between the patient and the image receptor will allow the receptor to intercept the primary beam while much of the scattered component will diverge enough to miss the receptor. In contact mammography, there is a strong emphasis on minimizing the loss of spatial resolution due to the focal-spot blurring (see Section This requires that the magnication factor be minimized, precluding the use of an air gap. On the other hand, in magnication mammography, dose and focal-spot loading limitations make the use of a grid inappropriate, and the magnication is achieved by moving the breast closer to the x-ray

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Grids for Mammography. The use of specically designed grids for mammography reduces the amount of scattered radiation detected and improves radiation contrast. This is especially signicant when imaging thick, dense breasts (Wagner, 1991; Yaffe et al., 1995). Grids are a standard feature of modern mammographic x-ray units.

Technical Aspects of Image Quality in Mammography

source, causing an air gap to be created. This serves to reduce the SPR slightly. Scatter Removal in Digital Mammography. In practice, for the three large-area digital systems (Types 1, 2, 3), it has generally been found advantageous to employ a grid, presumably to mainly reduce noise and so increase the SNR. Part of the required exposure increase when using a grid in screen-lm mammography is to replace the effect of the recorded scattered radiation in bringing the exposure to the image receptor to the point where the developed lm achieves the required OD. As will be discussed further below, the receptor contrast of a lm varies with OD. With a digital system, the display of image data is controlled electronically, so that the displayed image brightness and contrast are independent of x-ray exposure. It is therefore not necessary to compensate for the loss of the (unwanted) signal due to removal of scattered radiation. In digital mammography, any exposure increase necessitated by the use of the grid will be due only to its incomplete transmission of the primary radiation. The Type 4 system uses a narrow scanned beam of x rays, which reduces the SPR. In addition, the long, narrow detector with collimation at its entrance surface rejects much of the scattered radiation incident on the detector. Currently, a grid is not used with this type of system. Receptor Contrast in Screen-Film Systems. For screen-lm mammography, lmgradient characteristics determine how the spatially varying pattern of absorbed x-ray uence will be related to OD in the displayed mammogram. The photographic lm emulsion for mammography is designed with a characteristic curve such as that shown in Figure 3.8, which plots the OD (blackness) provided by the processed lm versus the logarithm of the x-ray exposure to the screen. Film provides non-linear input output transfer characteristics. The local gradient of this curve (see Figure 5.7) controls the display contrast presented to the radiologist. Where the gradient is small, a given increment of radiation exposure provides little change in OD, rendering structures imaged in this part of the curve difcult to visualize. Where the curve is steep, the lm provides excellent image contrast. The range of exposures over which contrast is appreciable is referred to as the latitude of the lm. Because the lm is constrained between two OD values, the base fog density of the lm (where there has been no intentional x-ray exposure) and the maximum density, Dmax, provided by the emulsion, there is a compromise

Figure 5.7. Comparison of gradients of various mammography lm types.

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between maximum gradient of the lm and the latitude that it provides. For this reason, some regions of the mammogram will generally be either underexposed or overexposed, i.e., rendered with sub-optimal contrast. Film gradient is affected by (1) lm type; (2) processing conditions (chemical concentration, temperature, time, agitation); (3) fog level (storage, safelight, light leaks); and (4) the OD. The trend is to use mammographic lms with a high lm gradient, i.e., with the maximum slope of the characteristic curve between 2.8 and 4.5. The maximum gradient occurs at different optical densities for different lm types (see Figure 5.7), which determines the optimum exposure for that lm. Figure 5.7 illustrates the importance of OD on mammographic image contrast. To ensure adequate contrast in all parts of the breast, the most radioopaque regions must be imaged with an OD of 0.8 or greater (Haus, 1999a; Meeson et al., 1999). To ensure that this is accomplished might require producing an imaging having an average OD of 1.8 or higher at the location of the sensor of the automatic exposure control. Absorbed dose might have to be increased to achieve the appropriate OD if a slower screen-lm combination is employed in order to reduce the effects of quantum noise or lm granularity (Haus, 1999b). From Figure 5.7, it is apparent that the range of optical densities over which the gradient is at least two-thirds of its maximum value extends from about OD 0.8 to about OD 3.5. Outside this range, the lm contrast falls off. When lms with increased maximum gradient are employed, the range of x-ray exposures that correspond to the region of high gradient on the lm (i.e., the exposure latitude) generally decreases. This imposes a compromise between maximum gradient and latitude in the choice of the lm used. For ODs


above about 3.5, visualization in mammograms is also affected by the limited dynamic range of the human eye unless localized bright lighting is employed (Meeson et al., 2000). Low lm contrast can be the result of using a lm with an inherently low gradient and processing the lm as recommended, or of using a lm with inherently high-contrast capability and processing the lm less than optimally. It is important to note that overall radiographic contrast is inuenced by both radiation contrast and lm gradient. Therefore, a screen-lm mammogram of acceptable contrast is best obtained by (1) use of appropriate beam quality, (2) breast compression, (3) use of a grid, (4) properly processed high-contrast lm, and (5) proper exposure to appropriate OD.
Downloaded from by guest on January 13, 2011 Receptor Contrast in Digital Mammography. In digital mammography, the signal stored in digital form is directly (or logarithmically) proportional to the amount of radiation transmitted through the breast over the entire range of intensities, from that of the unattenuated beam outside the breast to that through the densest, thickest part of the breast (see Figure 5.8). For this reason, the stored image reects the inherent radiation contrast very faithfully. Because the image is quantized, it is important to digitize the signal to an adequate precision. The number of bits required can be estimated by considering the attenuation factor of the breast and multiplying this number by the inverse of the precision required. This results in adequate precision even in the thickest, densest part of the breast. Some attenuation factors are shown in Table 5.2 for different combinations of breast thickness, tissue composition, and x-ray energy (monoenergetic) used for imaging. For example to achieve a minimum of 1 % precision, a breast that is 70 % broglandular and 6 cm thick, imaged at 20 keV (attenuation factor 66), will require 6600 digitization levels, or 13 bits if the digitization is linear. Logarithmic conversion compresses the range so that fewer bits of digitization are required. Note that both the required range and the absorbed dose can be reduced for thick, dense breasts by the use of increased x-ray energy. 5.3.2 Spatial Resolution

Figure 5.8. Signal-transfer characteristics in digital mammography. Digitized output signal is generally linear or logarithmic with x-ray uence absorbed by the detector. During image display, the recorded values can be arbitrarily mapped to shades of grey through a look-up table as shown in top portion.

to the lateral spreading of the image of a structural boundary, that is, the distance over which the OD change between the structure of interest and its surroundings takes place. Radiographic blurring results from three causes: geometric (focal-spot size), motion, and receptor characteristics. Geometric Unsharpness. The spatialresolution capability of the imaging system is determined in part by the effective size of the focal spot and by the degree of magnication of the anatomy at any plane in the breast. This is illustrated in Figure 5.9, where, by similar triangles, the unsharpness region due to the nite size of the focal spot is linearly related to the effective size of the spot and to the ratio of the object-imagereceptor distance (OID) to the source-object distance (SOD). Because the breast is a threedimensional structure, this ratio and, therefore, the geometric unsharpness will vary for different planes within the breast. The heat-loading capability of the x-ray tube target is related to the size of the focal spot. For smaller focal spots, the current through the x-ray tube must be reduced, necessitating increased exposure times and the possibility of loss of resolution due to motion of anatomical structures. Resolution loss due to geometric unsharpness can be controlled in part by

Spatial resolution describes the ability of an imaging system to record ne spatial detail. In mammography, such detail might be in the structure of microcalcications or spiculations around a mass. Resolution is degraded in the presence of radiographic blurring. Radiographic blurring refers

Technical Aspects of Image Quality in Mammography

Table 5.2. Factor by which the breast attenuates incident x rays Energy (keV) Breast thickness (cm) Fraction by mass of broglandular tissue 0% 18 3 4 5 6 8 3 4 5 6 8 3 4 5 6 8 3 4 5 6 8 5 9 16 28 87 3.9 6 10 15 38 2.6 3.6 5 7 13 2.2 2.9 3.7 5 8 30 % 8 16 33 66 268 5 9 16 29 88 3.1 4.5 6.6 10 20 2.4 3.3 4.4 6 11 50 % 11 24 53 117 569 6.6 12 23 44 153 3.5 5.2 8 12 27 2.6 3.6 5 7 13 70 % 14 35 84 205 1207 8 16 33 66 267 4 6 10 15 37 2.8 4 5.6 8 16 100 % 22 61 171 477 3729 11 25 55 123 612 4.6 7.6 13 21 57 3.1 4.5 6.6 10 21



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Data are given for different breast thicknesses, breast compositions, and x-ray energies. Calculations are for monoenergetic x rays. The breast is assumed to be composed of broglandular and adipose tissues.

minimizing OID/SOD, i.e., by designing the equipment with greater source-breast distances, by minimizing space between the breast and the image receptor, and by compressing the breast to reduce its overall thickness. Magnication is often used intentionally to improve the SNR of the image. This occurs because magnication of the breast anatomy reduces its spatial frequency in the plane of the image while the spatial frequency distribution of the lm-grain noise remains xed. Magnication is accomplished by elevating the breast above the image receptor, in

effect, reducing SOD and increasing OID. Under these conditions, resolution is invariably limited by focal-spot size, and the use of a small focal spot is critical. X-ray Source Size. Manufacturers of x-ray tubes describe the focal spot in terms of its nominal size. On modern equipment, the typical nominal focal-spot size for conventional contact mammography is 0.3 mm, while the nominal size of the smaller spot used primarily for magnication is 0.1 mm. The specications for x-ray focal-spot size tolerance, established by National Electrical Manufacturers Association (NEMA) or the International Electrotechnical Commission (IEC), allow the effective focal-spot size to be considerably larger than these nominal sizes. For example, the NEMA specication allows the effective focal-spot size to be 0.45 mm in width and 0.65 mm in length for a nominal 0.3 mm spot, and 0.15 mm in each dimension for a nominal 0.1 mm spot. Therefore, the limiting spatial resolution achievable with the mammography system will be lower than that predicted on the basis of the nominal focal-spot sizes. In addition, the source distribution is generally not uniform, and for the nominal 0.3 mm size often takes the form of two parallel lines running parallel to the anode cathode axis. The nominal focal-spot size is dened relative to the effective focal-spot size at a reference axis. As

Figure 5.9. Illustrating focal-spot (geometric) unsharpness in mammography.


shown in Figure 3.6, this reference axis, whose dened location can vary from manufacturer to manufacturer, is normally specied at some midpoint in the image. The effective size of the focal spot in the cathode anode dimension will monotonically increase from the anode side to the cathode side of the imaging eld. Normally, x-ray tubes are arranged such that the cathode side of the tube is adjacent to the patients chest wall, as the highest intensity of x rays is available at the cathode side, and the attenuation of x rays by the patient is generally greater near the chest-wall side of the image. Magnication Factor. Modern mammography systems typically have a source detector distance of approximately 650 mm. In contact mammography for a breast that is 50 mm thick under compression, the magnication factor is about 1.10. In magnication mammography, typically a magnication factor of 1.5 to 2 is employed. The greater this factor, the greater is the amount of geometric unsharpness that would result for a focal spot of a particular effective size. This is illustrated in Figure 5.10, in which the spatial frequencies at which the MTF falls to its 50 % and 10 % values are plotted versus the magnication factor. The MTF is discussed in Section 7.4.4. It is seen in Figure 5.10 that the nominal 0.3 mm focal spot is adequate for low magnication, but causes substantial image degradation at 1.5 magnication, i.e., the MTF falls to 50 % at a lower spatial frequency. Therefore, to mitigate the effects of geometric unsharpness, a smaller 0.1 mm focal spot is used for magnication mammography (Doi, 1977; Sickles et al., 1977). Receptor Blurring. For screen-lm radiography, light diffusion (spreading of the light emitted in the intensifying screen before it is recorded by the lm) causes blurring (Haus, 1990a;

1990b; Kimme-Smith, 1990; Yaffe, 1990). Factors involved include (1) the phosphor-layer thickness in the screen, (2) the phosphor-particle size, (3) presence of light-absorbing dyes and pigments in the screen, and (4) the quality of the screen-lm contact. To minimize receptor blurring, screen-lm combinations for mammography use a single highdenition screen in contact with a single-emulsion lm (Higashida et al., 1983). The single screen is used as a back screen for mammography because x-ray absorption (and the subsequent emission of screen light), being exponential, is highest on the side of the screen where the x rays enter and falls off rapidly with depth in the screen. This provides the shortest mean distance between the point of light creation and the point of absorption by the lm-emulsion surface, minimizing the lateral spread of light that gives rise to unsharpness. Both parallax and crossover, which also reduce spatial resolution, are eliminated in a single-backscreen conguration. To discriminate against light quanta travelling along oblique paths, the phosphor material of the screen is generally treated with a dye, which absorbs much of this light, resulting in a sharper image. Factors Inuencing Spatial Resolution in Digital Detectors. Because of cost and technical considerations, current digital mammography systems are not designed to provide as high a limiting spatial resolution as screen-lm mammography. For this reason, the spatial resolution is determined mainly by the detector characteristics, and the effect of the focal-spot size is relatively small in comparison. Receptor unsharpness in digital mammography is governed by three main factors: (1) signal diffusion between detector elements, (2) the active area of each element (aperture size), and (3) the pitch or center-to-center spacing between elements. In those digital mammography systems employing phosphor-based detectors, there is diffusion of light in the detector that is similar in nature to that which occurs in the screen-lm receptor. There are also important factors relating to sampling that inuence spatial resolution, and these are illustrated in Figure 5.11. All digital detectors are in some way divided into discrete elements, either at the x-ray absorption stage or in the readout. The dimensions of the x-ray sensitive portion (aperture) of the detector element or del determine the maximum possible spatial resolution that the detector can provide. For example, referring to Figure 5.11b, for a square del of d 0.1 mm, the detector response will rst fall to zero at a spatial frequency, fa, of 1/d or 10 cycles/mm along the

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Figure 5.10. Effect on system MTF of focal-spot size and magnication factor.

Technical Aspects of Image Quality in Mammography

Figure 5.11. Spatial sampling associated with a detector used for digital radiography. (a) The detector element (del) characterized by dimensions of the active element and the inter-del pitch. (b) The spatial-frequency response of a rectangular active del.

principal axes. There is another constraint, however, related to the detector pitch. This determines the number of samples per millimeter that the detector can acquire. If this is not adequately high, it gives rise to aliasing, in which artifactual signals, due to undersampling, degrade the quality of the image. The limiting frequency that can be represented correctly, without aliasing by a detector with pitch p is 1/2p. For a detector pitch of 0.1 mm, this allows a maximum frequency of 5 cycles/mm. Because the factors affecting resolution are system dependent, they will be discussed with reference to each of the current digital systems. Some detectors have part of their surface occupied by electronic components and conductive leads, so that only a fraction of the total detector area is sensitive to the incident radiation. The ll factor is dened as the ratio of the effective sensitive area of

the del aperture to the area dened by the product of the pitch in the x and y directions. Type 1: The image formed by the trapped electrons is intrinsically of very high quality. When the stimulable phosphor plate is placed in the reader and scanned with a laser beam, the red laser light can scatter from its original path and discharge traps that are laterally adjacent to it. This is a potential source of unsharpness. The sampling aperture is determined by the size of the laser beam, which is typically a Gaussian shape, and the dwell time on a given area (if the beam moves at constant velocity, the aperture shape will be trapezoidal). The sampling pitch is determined by the distance that the beam is allowed to move between samples. In the latest currently available systems, the pitch is approximately 50 mm. Due to opticalblurring effects, the aperture is greater than the pitch. The location of an element in the image is determined from the timing of the scanned laser beam. The stimulated blue light is collected by an optical detector, which is not spatially localizing. Therefore, scattering of this emitted light is not a source of unsharpness; however, any delayed emission by the phosphor will cause blur. Type 2: Light produced in the CsI phosphor can diffuse laterally and be recorded by detector elements adjacent to that in which the x-ray absorption took place. The needle-like structure of the CsI tends to direct the light down the length of the crystal and minimizes lateral spread. Lateral spread of light is reduced by the direct application of the CsI to the surface of the amorphous silicon plate containing the photodiode array. The del aperture of the detector is slightly smaller than the 100 mm inter-del pitch, which is determined by the spacing of the photodiode elements on the amorphous silicon plate. Type 3: The electric eld tends to direct the liberated charge carriers to the collection elements before the charge has much opportunity to diffuse laterally. This maintains high spatial resolution even when the thickness of the detector is increased to achieve increased quantum-detection efciency. Type 4: The optical image from a CsI layer is transferred to the CCD through a beroptic faceplate. There is the potential for some light diffusion in the beroptics; however, this can be controlled by the use of extramural absorber (a lightabsorbing dye) between the individual glass bers. The CCD electronics must be properly synchronized with the motion of the scanning system to avoid image blur. The del aperture and inter-del pitch are determined primarily by the characteristics of the CCD. In this system, they are both

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approximately 50 mm, with the aperture slightly smaller than the pitch. Type 5: This system benets from the principles of the Type 3 system with respect to direct charge conversion and electrostatic collection. In addition, because of the linear nature of the detector modules, scattered radiation should be efciently reduced. Motion Blurring. The use of a long exposure time can result in image blurring caused by motion. In mammography, most motion blurring is caused by movement of the breast during exposure. It can be minimized by using a short exposure time (less than 2 seconds) and by compressing (thereby immobilizing) the breast. The kilovoltage setting for x-ray tube voltage can be increased for thick, dense breasts to keep exposure times less than 2 seconds. Magnication techniques generally require longer exposure times; higher-speed screenlm combinations can be used to reduce exposure time for magnication mammography. In digital mammography, the effect of motion blurring is similar to that in screen-lm imaging. The amount of blurring depends on the speed of the patient motion and the duration of the exposure. It is important to note, however, that for considerations of blur the exposure time in the case of the large-area digital systems (Types 1 through 3) is the complete exposure time, while for a scanning system only part of the breast is exposed at any one time. For this reason, even though the overall exposure time is generally longer for a scanning system, the time that x rays expose a particular part of the breast (i.e., the time that affects blurring) is only a small fraction of the total exposure time. For scanning systems, motion can, however, cause misregistration artifacts between the anatomy that is imaged before a motion occurs and that imaged after. Compromise Between Geometric and Motion Unsharpness. In many cases, for a given image-receptor sensitivity (a specied amount of radiation required at the image plane), there is a trade-off between motion blur and geometric unsharpness. If one attempts to reduce motion blur, then a greater x-ray output must be available. Short of a radical improvement in the basic x-ray tube performance, this can be accomplished only by either increasing tube current or reducing the distance from x-ray tube to image receptor. The former requires increasing the focal-spot size. In either case, geometric unsharpness will become greater. Reducing distances also makes patient positioning for the examination more difcult. It is

important for the radiographer to enlist the cooperation of the patient, if possible, to attempt to minimize motion of the breast during the exposure. Image Optimization. As discussed in Section 7.4.4 and ICRU Report 54 (1995), the overall MTF of the system is the product of the component MTFs. Analysis of the MTFs of the system components is helpful in determining which is the limiting factor controlling spatial resolution. In some situations, the x-ray unit is the major cause of image blur either as a result of motion blur caused by long exposure times or as a result of geometric blur due to the combination of focal-spot size and magnication. In these situations, a higher speed, slightly less-sharp mammographic screen-lm combination might produce mammograms with less overall image blur, because shorter exposure times or a smaller focal-spot size can be selected than is possible with lower-speed highresolution combinations. For example, a higher speed screen-lm combination might be appropriate for magnication techniques (in which geometric blurring can be a limiting factor) to reduce exposure time (minimize motion blur) and to reduce absorbed dose. The MTF data in Figure 5.10 include the effects of both geometric unsharpness and the MTF of the image receptor. As magnication is increased, the image projected onto the image receptor is larger and the effective MTF associated with the image receptor (referenced back to the location of the breast) improves. For this reason, the MTF performance initially improves with magnication until the degradation associated with focal-spot unsharpness begins to dominate at higher magnications. In digital mammography, the limiting spatial resolution is typically much lower than that of a screen-lm system. For this reason, moderate levels of magnication should result in an improved overall MTF to a greater extent than for screen-lm receptors. So while the primary benet of geometric magnication with lm is to improve image SNR, in digital mammography it is to improve both spatial resolution and also possibly the SNR. 5.3.3 Image Display for Digital Mammography

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As illustrated in Figure 5.8, the characteristics for acquisition and display are decoupled in digital mammography. Generally, the relation between the x-ray energy uence transmitted through the breast (and absorbed by the detector) and the recorded digital signal is essentially linear, while the characteristic curve for display is variable and can be adjusted both prior to hard-copy printing of

Technical Aspects of Image Quality in Mammography

the digital image and interactively during display on a video monitor. To display the image, a lookup table (see Figure 5.8) is used to transform the recorded digital data either into optical densities on a laser-printed lm or brightnesses on a video monitor. The nature of this transformation can be controlled by the user, and in the case of soft-copy display it can be varied interactively by the radiologist to facilitate image interpretation. Therefore, provided that the image has been acquired with an adequate number of bits of digitization, there are no overriding limitations related to the characteristic curve of the receptor as there are with screenlm mammography. Thus, the image created with a single x-ray exposure can be presented in many ways. On the other hand, there are clearly practical limitations to the number of hard-copy printouts that might be used to display a single exposure and to the amount of time that a radiologist can spend manipulating the soft-copy display. Determination of optimal strategies for display of digital mammograms is currently an area of active research (Hemminger et al., 1998; Kundel et al., 1999; Pisano et al., 2000a) both for soft-copy display (Bloomquist et al., 2003; Hemminger et al., 1999; Kim et al., 2006; Krupinski et al., 1999; Van Ongeval et al., 2008; Zuley et al., 2006) and hardcopy presentation (Chan et al., 1987b). Image Viewing for Film and Hard-Copy Digital Mammography. To allow visualization of as much of the information recorded in the mammogram as possible, it is essential that the viewing conditions are optimal. Mammograms should be interpreted under conditions that provide good visibility, comfort, and minimal fatigue. Viewing-transillumination systems are available that have been specically designed to produce the appropriate luminance levels for reading mammograms. It has been recommended that illuminators for lm mammograms be capable of producing a luminance of at least 3000 cd m22 (nit) (Haus et al., 1993). The illuminator surface should provide diffused light of uniform brightness. The luminance level must be sufcient to illuminate areas of interest in the radiograph. Ideally, all viewboxes in a mammography facility should have lamps of the same color. The contrast sensitivity of the eye (the ability to distinguish small differences in luminance) is greatest when surroundings are of about the same brightness as the area of interest. Therefore, to see detail in a mammogram, it is important to reduce glare to a minimum, to avoid surface reections, and to reduce ambient light level to approximately

that reaching the eye through the mammogram. Glare and reections can be reduced by locating illuminators away from bright surroundings such as windows, by turning off surrounding viewboxes when not in use, and by either using masks to cover unused portions of a viewbox or covering lowdensity areas in the mammogram being examined (Kimme-Smith et al., 1997). Subdued lighting is preferred in the viewing room. It is also important to have a variable high-output light source (with appropriate masks) to view high-OD areas on the mammogram, and to ensure that lms are properly exposed and processed. For hard-copy display, it must be appreciated that the maximum OD and the latitude of laser lms are lower than that available with mammography lm. It is, therefore, imperative that the lookup table for printing the image be optimized and/or that appropriate image processing is applied. This is facilitated if there is a what-you-see-is-what-you-get preview available on a monitor so that the image presentation can be adjusted, if necessary, prior to printing. Image Viewing for Soft-Copy Digital Mammography. High-resolution display monitors are now available to meet the demanding requirements (number of pixels, luminance, speed of loading images, image refresh rate, multiple-image capacity) of displaying digital mammography images. For soft-copy viewing, it is important to realize that the brightness of available displays is far less than that of mammographic viewboxes and that the dynamic range of the display is less than that of mammography lm. Thus great care must be taken in setting up the display conditions and in minimizing ambient light in the reading area. In order to obtain the optimal combination of dynamic range and contrast performance from the monitors, they should be set up according to a perceptually equalized grey scale, i.e., that the maximum number of just-noticeable differences can be realized from the monitors. The DICOM committee has established a gray-scale-display function (DICOM, 2007) for this purpose, and monitors should be adjusted to conform to this standard. In particular, a method of preventing stray light from nearby viewboxes from reecting off the digital display is essential. If multiple monitors are used, their intensities must be carefully matched, and the monitors must have uniform resolution across their entire surface. Because in most cases it is not possible to view the entire image at full spatial resolution at one time, it is frequently necessary to alternate between an overall view of the entire mammogram at reduced resolution and a

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zoomed presentation of regions of interest at full resolution. In addition, it might be necessary to adjust the grey-scale presentation of the image during viewing to ensure that all pertinent information acquired in the digital mammogram is displayed optimally. These image manipulations frequently have the result that the time required by the radiologist to interpret a digital mammogram is greater than that required for screen-lm mammography (Berns et al., 2006). 5.3.4 Artifacts

Artifacts are unwanted features that appear in the image, but are unrelated to anatomical structures within the breast. Artifacts have two detrimental effects on mammographic quality: (1) they can mask the detection or impair the characterization of lesions by adding clutter (Kundel, 1986) or noise to the image, and (2) they can simulate lesions that do not exist. In screen-lm mammography, artifacts can be caused by the x-ray source, beam lter, compression device, breast-support table, grid, screen, lm, processor, and darkroom. These have been well documented in the literature (Haus and Jakulski, 1997), and their evaluation should be part of any quality-control program for mammography (Hendrick et al., 1999). In digital mammography, all of the artifacts caused by components preceding the image receptor are still possible. In addition, there can be artifacts caused by non-uniformities in the detector response over the image area. These can be a result of improper at-elding, errors in scanning (Types 1, 4 and 5), or mismatches in stitching together sub-images from detectors that contain multiple modules (Types 4 and 5). Artifacts can also be caused by non-uniformity or miscalibration associated with the hard-copy or soft-copy display systems (Roehrig et al., 1995). With good design and with proper maintenance and system calibration, it should be possible to control or eliminate these artifacts. It should be noted, however, that the software elements of the digital system can mask certain deciencies and still present an image that appears to be of reasonable clinical quality. Nevertheless, depending on the particular problem and the manner in which it is compensated by the software, at some point it might be necessary to correct the underlying problems to avoid the possibility of loss of diagnostic performance. 5.3.5 Absorbed Dose

screen-lm mammography is determined by the amount of radiation needed to produce a lm of the desired OD. That OD is chosen on the basis of having as much of the breast as possible imaged at the peak gradient of the lm. Factors that affect absorbed dose in screen-lm mammography include: (1) the quantum-detection efciency of the screen; (2) the conversion efciency of the phosphor; (3) the sensitivity of the lm; (4) the time, temperature, and chemical activity of lm processing; (5) the selected OD level; (6) the breast-tissue composition and thickness; (7) the x-ray-tube target material, ltration, and kilovoltage setting; (8) the efciency of the grid; and (9) the degree of magnication. The American College of Radiology (ACR) Mammography Accreditation Program requires that the mean glandular dose for a 4.5 cm thick breast-phantom image in screen-lm mammography be less than 3 mGy. The average reported mean glandular dose per mammographic image for all facilities in the USA inspected under the Mammography Quality Standards Act (MQSA) in the rst half of 1997 was 1.6 mGy (Spelic et al., 1995). This is actually an increase from the value of 1.27 mGy previously reported by ACR for successfully accredited facilities. It is important to note that if the absorbed dose is too low, mammographic image quality can be compromised (Young et al., 1994). Digital Mammography. In digital mammography, a different approach should be followed. The dose level should be set to establish the required SNR for the image. For example, the SNR must be adequate to allow the reliable detection of microcalcications on a background of broglandular tissue. The display can then be adjusted separately to provide the desired image brightness and contrast. Factors affecting the required dose are the quantum-detection efciency of the detector, its ll factor, and items 6 through 9 listed above for screen-lm mammography. Because of the ability to adjust display contrast, more penetrating x-ray beams might be suitable for digital mammography. When combined with an increased quantumdetection efciency and a reduced receptor noise, the resulting increase in detective quantum efciency allows for the possibility of dose reductions in digital mammography compared to screen-lm. Such a dose reduction was observed in the DMIST study, in which it was found that mean glandular doses were 1.62 mGy for digital technology compared to 1.9 mGy for screen-lm mammography, a relative reduction of 14.7 % (Bloomquist et al., 2006). This occurred despite an initial

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Technical Aspects of Image Quality in Mammography

attempt to match doses between the screen-lm and digital examinations performed in the trial. Because at some of the study sites doses were

successfully matched, the expected dose reduction possible with digital mammography is probably greater than 14.7 %.

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Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


6. Patient Dosimetry in Mammography

There is a quantied association between absorbed dose in the breast and an increased incidence of breast cancer (NAS/NRC, 2006). Therefore, knowledge of breast doses received in medical procedures is of considerable importance. There are two fundamental reasons for assessing breast dose from mammography. First, dose assessment provides a means for setting and checking standards of good practice, as an aid to the optimization of the radiation protection of the patient. Second, estimates of the absorbed dose in the breast are needed to assess radiation detriment so that radiological techniques can be justied in relation to the expected benets, both for screening and for diagnosis of women suspected of having breast cancer. Patient dosimetry is of particular interest in the case of screening, as this generally involves a large group of asymptomatic women exposed to ionizing radiation, with only a relatively small proportion of women examined in which the disease is detected, i.e., those who actually benet directly from earlier detection. For example, the overall breast-cancerdetection rate in the Dutch national screening program was 4.8 per 1000 women in 2005 (NETB, 2007). With regard to benets of breast-cancer screening employing mammography, the National Evaluation Team for Breast Cancer Screening in the Netherlands reported that in 2005 breastcancer mortality in women aged 55 to 74 years was 25.9 % lower than in 1986 1988 before the nationwide breast-cancer-screening program was started. This benet must be compared with any risks associated with mammography. One of these risks is radiation-induced breast cancer, and the probability of this occurring is related to the dose received by the breast. Numerous surveys that have included mammography have demonstrated that there is a considerable variation in the doses delivered to patients from the same type of x-ray examination conducted in different facilities, or even within a single facility. Without some form of patient-dose monitoring, it is difcult to know the performance of a mammography facility and to judge how it compares with generally accepted practice. As an aid to the optimization of the radiation protection of the patient, reference values, variously called reference dose values (EC, 1996a), diagnostic reference levels (ICRP, 1996), or guidance levels (IAEA, 1996), can be specied for particular x-ray imaging tasks. Local performance can be checked against these reference values by periodic measurement as part of a quality-assurance program. For these purposes, clearly dened quantities are required that can be easily measured with readily available instruments of sufcient precision and accuracy. Consequently, dosimetric quantities associated with the primary x-ray beam (e.g., air kerma at a specied point on the beam axis) are measured for mammography systems. In mammography, mean glandular dose (MGD) to the breast is generally considered to be the most relevant dosimetric quantity (Hammerstein et al., 1979). It is not measured directly, but is derived from incident or entrance air kerma for a specied series of patients or a specied phantom using dose conversion coefcients (ICRU, 2005), as will be described below. It is important to ensure that efforts to reduce patient doses do not also reduce doses or dose rates to the image receptor to such an extent that the quality of the images is degraded to an unacceptable level. Such a poor image quality can result in a repeat mammography, with the total dose to the breast larger than necessary. Image quality can be affected by inadequate doses or dose rates in ve distinct ways: (1) In the non-digital imaging systems used in mammography, optical density or brightness and the displayed contrast (lm gradient) of the image depends on the dose received by the image receptor. If the dose is too low, this can result in images in which important structures are too faint to be clearly discerned and/or are rendered with poor contrast. (2) Too-low a dose rate can necessitate lengthy exposure times and result in image blurring due to patient motion. (3) Dose reduction by increasing the tube voltage and thereby allowing a reduction in tube

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# International Commission on Radiation Units and Measurements 2009


current or exposure time to maintain the same dose to the image receptor can degrade image quality by decreasing radiation contrast. (4) As medical imaging systems have become more sensitive, using lower doses to achieve images of satisfactory density or brightness, there is an increased likelihood that random variations in the photon uence rate reaching the image receptor will give a disturbing mottled appearance to the image (see Section 5.2). (5) The sensitivity of the imaging system can often be improved by increasing the thickness of the sensitive layer of the image receptor so that it absorbs more of the incident x-ray energy. For the majority of image receptors that re-emit the absorbed energy in the form of visible light, thicker sensitive layers result in wider spatial dispersion of the emitted light before the image is recorded. Greater sensitivity, and hence the possibility of using lower doses, is consequently gained at the expense of poorer spatial resolution in the image. Procedures for checking that doses have not been reduced to such an extent that inadequate optical density, excessive noise, poor spatial resolution, or lack of contrast prevents reliable diagnosis should be an essential component of a quality-assurance program for mammography. Phantoms that can be used to assess image quality in mammography are described in ICRU Report 48 (ICRU, 1992). More fundamental methods for assessing the quality of mammograms are described in Section 7 of the present Report. The normal female breast contains various types of tissue, i.e., glandular tissue (lobuli, ducts and acini), subcutaneous fat, and skin (see Section 2.2 and Figure 2.1). The distribution of glandular tissue within the breast is not uniform, and consequently

some parts of the breast are more sensitive to tumor induction than others. An appreciably larger amount of glandular tissue is present in the outer upper part than in the lower inner part. This corresponds to the distribution of spontaneous tumors in the different parts of the female breast (Haagensen, 1971). For mammography, the mean mammary glandular dose, DG, is the recommended quantity for the establishment and use of diagnostic reference levels, or DRLs (IAEA, 2001; ICRP, 2001; IPEM, 2004). Values of dose-conversion coefcients are available as a function of the rst half-value layer, HVL1, for compressed breasts of various thickness and composition (see Tables 6.1, 6.2, and 6.3), as well as for reference phantoms. It is important to note that these conversion coefcients are breastmode dependent (see Section 6.2.3).

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Specication of Dosimetric Quantities Used in Mammography

Application-specic dosimetric quantities have been dened for measurement and computation in medical x-ray imaging (ICRU, 2005). Several of these quantities, relevant for mammography, are summarized in this section. 6.1.1 Incident Air Kerma and Incident Air-Kerma Rate

The incident air kerma is the air kerma from the incident beam on the central x-ray beam axis at the focal-spot-to-surface distance, dFSD, i.e., at the skin-entrance plane (see Figure 6.1). Only the primary radiation incident on the patient or phantom, and not the backscattered radiation, is included. It is given the symbol Ka,i. Unit: J kg21; special name: gray (Gy).

Table 6.1. Conversion coefcients, cG (mGy mGy21), for calculation of mean glandualar doses for breasts of 50/50 composition and thicknesses from 2 cm to 11 cm, for values of the HVL1 ranging from 0.30 mm Al to 0.60 mm Al (Dance et al., 2000) Breast thickness (cm) 2 3 4 4.5 5 6 7 8 9 10 11 HVL1 (mm Al) 0.30 0.390 0.274 0.207 0.183 0.164 0.135 0.114 0.098 0.0859 0.0763 0.0687 0.35 0.433 0.309 0.235 0.208 0.187 0.154 0.130 0.112 0.0981 0.0873 0.0786 0.40 0.473 0.342 0.261 0.232 0.209 0.172 0.145 0.126 0.1106 0.0986 0.0887 0.45 0.509 0.374 0.289 0.258 0.232 0.192 0.163 0.140 0.1233 0.1096 0.0988 0.50 0.543 0.406 0.318 0.285 0.258 0.214 0.177 0.154 0.1357 0.1207 0.1088 0.55 0.573 0.437 0.346 0.311 0.287 0.236 0.202 0.175 0.1543 0.1375 0.1240 0.60 0.587 0.466 0.374 0.339 0.310 0.261 0.224 0.195 0.1723 0.1540 0.1385


Patient Dosimetry in Mammography

Table 6.2. Conversion coefcients, cG, for calculating DG for a 4.5 cm thick breast (50 % adipose/50 % broglandular tissue) from Ka,i [after ACR (1992), with permission, and from ICRU Report 74 (ICRU, 2005)]. HVL1/ mm Al X-ray tube peak voltage, kV Mo/30 mm Mo target-lter combination. 23 0.23 0.24 0.25 0.26 0.27 0.28 0.29 0.30 0.31 0.32 0.33 0.34 0.35 0.36 0.37 0.38 0.39 0.40 0.41 0.42 0.43 0.44 0.45











W/ Ala 45

0.124 0.129 0.133 0.138 0.144 0.148 0.154 0.159 0.164 0.169 0.174 0.179

0.132 0.137 0.141 0.146 0.151 0.156 0.161 0.166 0.171 0.176 0.181 0.186

0.139 0.144 0.148 0.153 0.158 0.163 0.168 0.172 0.177 0.182 0.187 0.192

0.146 0.151 0.155 0.161 0.165 0.170 0.174 0.179 0.184 0.189 0.194 0.198

0.153 0.157 0.162 0.166 0.171 0.176 0.180 0.185 0.190 0.195 0.200 0.204

0.158 0.163 0.168 0.172 0.177 0.181 0.186 0.192 0.196 0.201 0.205 0.210

0.164 0.169 0.173 0.178 0.182 0.187 0.193 0.197 0.202 0.206 0.211 0.216

0.170 0.174 0.180 0.185 0.189 0.194 0.198 0.203 0.208 0.212 0.217 0.221

0.176 0.181 0.186 0.190 0.195 0.200 0.203 0.208 0.212 0.218 0.222

0.182 0.187 0.192 0.196 0.201 0.204 0.209 0.213 0.219 0.223 0.228

0.182 0.187 0.192 0.196 0.201 0.205 0.210 0.214 0.219 0.223 0.228 0.233

0.194 0.200 0.205 0.211 0.217 0.221 0.227 0.233 0.237 0.243 0.247 0.252 0.257 0.262 0.267 0.271

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W/Al target-lter combination, peak tube voltage 45 kV, lter thickness 1.6 mm.

Table 6.3. Conversion coefcient, cG, that relates to Ka,i to DG for a 5 cm thick breast having a central region of 50 % adipose and 50 % broglandular tissue, by mass (tissue compositions according to Hammerstein et al., 1979) HVL1/ mm Al Rosenstein et al. (1985)a Dance (1990)b Wu et al. (1991) 0.146 0.172 0.195 Jansen and Zoetelief (1994)c Wu et al. (1994)d Dance et al. (2000)e

0.30 0.35 0.40 0.45 0.50 0.55 0.60 0.65

0.171 (0.160) 0.217 (0.200) 0.314

0.164 0.187 0.209 0.232 0.258 0.287 0.310 0.332

0.168 (Mo/Mo) 0.1910.198 (W/MoMo/Mo) 0.2210.229 (Mo/RhRh/Rh) 0.257 (Rh/Rh) 0.273 (W/Rh) 0.294 (W/Rh)

0.1510.153 0.1740.180 0.1960.209 0.2200.239 0.2420.260

0.164 0.1880.194 0.2160.224 0.2410.253 0.270 0.296 0.321

From ICRU Report 74 (ICRU 2005), Table E.2. a Conversion coefcients for tungsten targets; conversion coefcients given in parentheses refer to Mo and Mo/W targets b HVL1 range: 0.250.45 mm Al for Mo/Mo; 0.45 0.70 mm Al for W/Mo; 0.500.80 mm Al for W/Rh; 0.550.90 mm Al for W/Pd; 0.50 2.00 mm Al for W/Al. c J. T. Jansen and H. Zoetelief (personal communication). Target/lter materials include Mo/Mo, W/Mo, Mo/Rh, Rh/Rh, and W/Rh. d Lower values refer to Mo/Rh and higher values to Rh/Rh. Values can differ by about 5 % depending on differences in tube voltage. e Target/ lter combinations also include Mo/Mo, Mo/Rh, Rh/Al, Rh/Rh, and W/Rh (Dance et al., 1990).

The incident air kerma is approximately related to the air-kerma free-in-air at any other distance, d, from the tube focal spot, Ka(d), by the

inverse-square law. Thus, Ka;i Ka d

d dFSD

2 : 6:1


Table 6.4. Backscatter factors for a semi-circular PMMA phantom of 10 cm radius and 5 cm thickness Tube voltage (kV) Target: Mo Filtration: 30 mm Mo HVL1/ mm Al 24 25 26 28 30 32 34 35 36 38 40 0.282 0.295 0.306 0.325 0.340 0.353 0.364 0.369 0.373 0.381 0.388 B Target: Mo Filtration: 25 mm Rh HVL1/ mm Al 0.328 0.343 0.356 0.375 0.391 0.403 0.412 0.416 0.420 0.427 0.433 B Target: Rh Filtration: 25 mm Rh HVL1/ mm Al 0.297 0.316 0.330 0.362 0.391 0.418 0.441 0.452 0.462 0.481 0.497 B

Figure 6.1. Simple exposure arrangement for mammography showing some of the dosimetric and geometric quantities recommended for determination of patient dose. Point A is location of the ionization chamber for measuring air kerma with the phantom in place, according to the ACR protocol. Alternatively, the chamber can be positioned at Point B with no phantom or breast in the beam, to measure output, Y.

1.08 1.09 1.09 1.09 1.10 1.10 1.10 1.11 1.10 1.11 1.10

1.09 1.09 1.10 1.10 1.11 1.11 1.11 1.12 1.11 1.12 1.12

1.09 1.09 1.10 1.11 1.11 1.12 1.12 1.13 1.13 1.13 1.14

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Results, given for three x-ray tube assemblies, are for a semicircular eld with a 10 cm radius at the phantom surface and dFSD 65 cm (based on data of Kramer et al., 2001).

Equation (6.1) is an approximation because there are several small corrections due to attenuation in air and scatter in air and x-ray source structures. The incident air kerma can be easily calculated from the x-ray tube output, Y(d) (see Section 6.2.2), provided the dFSD and the tube-current-exposuretime product, PIt, are known for the specied radiation quality. The incident air-kerma rate, Ka,i, is the quotient of dKa,i by dt, where dKa,i is the increment of incident air kerma in the time interval dt, thus

spectrum, the x-ray eld size, and the thickness and composition of the patient or phantom (ICRU, 2005). Some typical backscatter factors for mammography are given in Table 6.4. The entrance-surface air-kerma rate, Ka,e, is the quotient of dKa,e by dt, where dKa,e is the increment of entrance surface air kerma in the time interval dt, thus K a;e

dKa;e : dt


K a;i

dKa;i : dt


Unit: J kg21 s21, or Gy s21.

Unit: J kg21 s21, or Gy s21. 6.1.3 6.1.2 Entrance-Surface Air Kerma and Entrance-Surface Air-Kerma Rate Dose-Conversion Coefcients for Mammography

The entrance-surface air kerma is the air kerma on the central x-ray beam axis at the point at which the x-ray beam enters the patient or phantom (see Figure 6.1). The contribution of backscattered radiation is included. It is given the symbol Ka,e. Unit: J kg21; special name: gray (Gy). The entrance-surface air kerma is related to the incident air kerma by the backscatter factor, B. Thus Ka;e Ka;i B: 6:3

A dose conversion coefcient, c, relates a dosimetric quantity to some other quantity, i.e., the normalization quantity, which can be readily measured or calculated in practice in the clinical situation. In general c specified dosimetric quantity : normalization quantity

The backscatter factor depends on the x-ray


In mammography, for estimating the probability of stochastic effects, the specied dosimetric quantity is the MGD, DG. Conversion coefcients are available relating the incident air kerma (the

Patient Dosimetry in Mammography

normalization quantity), Ka,i to DG. Thus cG;Ka;i DG : Ka;i 6:5

Unit: J kg21 J21 kg, or Gy Gy21. The MGD to the breast is determined by multiplying the incident air kerma, Ka,i, by the appropriate conversion coefcient denoted as cG, i.e., DG Ka;i cG : 6:6

The incident air kerma can be calculated from measurements of output from the x-ray system as described in Section 6.2.2, and the determination of cG is discussed in Section 6.2.3.

6.2 6.2.1

Method for Determination of MGD, DG Determination of Incident Air Kerma, Ka,i

The incident air kerma, Ka,i, can be calculated from the measured value of the x-ray tube output, Y(d), in terms of air kerma per tube-currentexposure-time product at a distance, d, from the focal spot of the mammography unit (EC, 1996b). The tube-current-exposure-time product, PIt (where here t is the time), that was employed for a given exposure of the breast or phantom is determined either from the manual settings used or from the AEC postexposure readout pertaining to an actual breast examination. In addition, it is necessary to know the focus-to-surface distance, dFSD, for the compressed breast. The value of dFSD can be derived from the focus-to-breast support distance dFBSD and the compressed breast thickness, t, i.e., dFSD dFBSD 2 t. The calculation of incident air kerma from radiation output is given by Ka;i d2 Y d PIt : d2 FSD 6:7

The magnitude of the x-ray tube output will depend upon the design of the tube, the tube voltage, and ltration, and can change as the tube ages. The output, Y(d), can be measured for a particular target, lter material, and kV using an ionization chamber calibrated in terms of air kerma at radiation qualities appropriate for mammography. In the case of mammography, it will be necessary to perform the measurement at a distance of less than 1 m from the focal spot and apply a correction according to the inverse-square law. If the measurement is performed at the same distance from the focal spot as the entrance surface of the breast for which dose is to be estimated, the need to perform inverse-square corrections will be eliminated (see Figure 6.1). A reference position should be selected, preferably at a central location 6 cm from the chest wall edge (EC, 1993). The ionization chamber should be placed in the x-ray beam above the breast-support plate at a xed distance from the x-ray source and beneath the compression paddle. An exposure with a given value of PIt is made, and the resulting air kerma is measured. This is most conveniently done using manually adjusted exposure factors. For this measurement, no breast or phantom should be in the beam so that the measurement will be made essentially without backscatter. In the ACR method (ACR, 1999), the output is measured with the midline of the ionization chamber placed adjacent to the phantom, at the level of the entrance surface of the phantom. Under these circumstances, care should be taken to avoid a signicant contribution from scattered radiation. The compression plate should be between the x-ray tube and the ionization chamber. Some typical values of output from modern mammography machines, measured at d 60 cm, are shown in Figure 6.2. 6.2.3 Conversion Coefcients for Dosimetry

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X-Ray Tube Output

The x-ray tube output can be used in conjunction with the inverse-square law to calculate the air kerma incident on a breast or a phantom if the tube-current-exposure-time product is known. The x-ray tube output, Y(d), is dened (ICRU, 2005) as the quotient of the air kerma, Ka(d) at a specied distance, d, from the x-ray-tube focal spot by the tube-current-exposure-time product, PIt. Thus, Y d Ka d : PIt 6:8

Unit: J kg21 C21, or Gy (m As)21.


The choice of cG is dependent on the model that is selected to represent the breast. For any model, cG will depend on the thickness of the breast, its composition, and the quality of the x-ray beam, which to rst order can be described by the rst half-value layer, HVL1. The HVL1 is typically specied for commercially pure aluminum, and its measurement is described in Section 6.2.4. For many purposes, and particularly for quality control, the breast can be approximated by a standard phantom. The advantage of this approach is that consistent, reproducible measurements of air kerma can be made at periodic intervals over


Figure 6.3. Some models of the breast used for dosimetry calculations. Figure 6.2. Output of x-ray tubes for various target-lter combinations. Filter thickness can vary among manufacturers; typical thicknesses are 0.03 mm of Mo and Rh used with a Mo target and 0.05 mm of Rh used with a W target.

months or years. In the method described in the American College of Radiology (ACR) protocol (ACR, 1999), Ka,i is determined for imaging a mammographic phantom, approximately 4.2 cm thick overall and composed mainly of polymethyl methacrylate (PMMA). This is considered to be equivalent in attenuation, at x-ray energies used for mammography, to a compressed breast of average composition that is approximately 4.5 cm thick. The European Commission (EC) recommends Ka,i measurements for 5 cm thick breasts or alternatively for a 4.5 cm thick PMMA phantom (used in practice to mimic a standard breast assumed to be composed of 50 % adipose and 50 % broglandular tissue) (EC, 1996b). Tables 6.2 and 6.3, also presented in ICRU Report 74 (ICRU, 2005), provide data on cG for dosimetry based on air-kerma measurements with standard phantoms as used in the EC and ACR protocols, respectively. This approach is appropriate for comparing doses from different mammography units or for monitoring changes in dose over time on a particular unit. For risk assessment the method is less suitable as it does not take into account the individual compressed thicknesses and composition of the breasts of the women examined. More generally, and especially for risk assessment, it is desirable to estimate the dose to breasts of different thickness and composition. It is therefore necessary to have conversion factors for particular breast compositions, over a range of thicknesses for each composition. These are most frequently obtained through Monte Carlo calculations (Boone, 2002; Dance, 1990; Rosenstein et al., 1985; Wu et al., 1994; Zoetelief and Jansen, 1995). The values of cG will depend on the model of the breast that is employed in these calculations. Various models and the results obtained by different investigators in

calculating cG are discussed in detail in Appendix E of ICRU Report 74 (ICRU, 2005). Dosimetry models of the breast vary in complexity, as shown in Figure 6.3. The simplest model treats the breast as a homogeneous block of tissue. With increasing sophistication, a layer representing the skin is added, then a subdermal layer of adipose tissue, and then a central region consisting of some mixture of adipose and glandular tissue. It is assumed that it is the dose to the glandular tissue that is responsible for carcinogenesis and other radiation-related risks. In fact, the structure of the breast is more complex. What is referred to as glandular tissue consists of a heterogeneous arrangement of actual glandular or epithelial tissue, also known as parenchyma, and brous tissue or stroma. Collectively this combination of tissues is referred to as broglandular tissue, and generally the majority of this is brous tissue. The relative risks of dose to the brous and glandular tissues are not known. In the breast, the broglandular tissues are generally interspersed with pockets of fat. It must, therefore, be recognized that the models used for dosimetry are gross simplications of the actual tissue arrangements. In Appendix E of ICRU Report 74 (ICRU, 2005), a number of other sources of uncertainty related to estimation of breast doses are outlined. Data indicating that the composition of the average compressed female breast deviates from the commonly assumed 50 %/50 % adipose/broglandular tissue, by mass, have been published (Geise and Palchevsky, 1996; Klein et al., 1997; Young et al., 1998; Zoetelief et al., 2006). This nding has recently been supported by data from Yaffe et al., 2009. Notwithstanding, for practical radiationprotection purposes, it is still useful to estimate breast doses using such simplied models, as they allow an acceptable estimation of risk. The dose conversion coefcients, cG, for spectra for Mo/Mo target/lter combinations as a function of HVL1 for

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Patient Dosimetry in Mammography

Table 6.5. Typicala HVL1 values, in mm Al, for mammography units with different target and lter combinations, operated at various tube voltages Target and lter materials Tube voltage (kV) HVL1 (mm Al) without compression plate 0.28 0.32 0.34 0.35 0.36 0.30 0.36 0.40 0.41 0.33 0.35 0.37 0.38 0.41 0.48 0.51 0.53 0.36 0.44 0.48 0.50 0.31 0.34 0.39 0.42 HVL1 (mm Al) with compression plate 0.34 0.37 0.38 0.39 0.40 0.34 0.40 0.44 0.46 0.37 0.39 0.41 0.42 0.43 0.51 0.54 0.56 0.40 0.48 0.53 0.55 0.36 0.40 0.45 0.48

Figure 6.4. Ratios of conversion coefcients, cG, for breasts with composition different from 50 % broglandular / 50 % adipose, for a HVL1 of 0.35 mm Al. Adapted from ICRU Report 74 (ICRU, 2005) and simplied to show only the data from Dance et al. (2000).

breasts of various thickness and reference composition (50 % broglandular tissue and 50 % adipose tissue, by mass) have been tabulated in Dance et al. (2000) and are reproduced for convenience in Table 6.1. A graph to guide modication of these factors for breasts that are fattier or more broglandular in composition is given as Figure E.3 of ICRU Report 74 (ICRU, 2005). This is reproduced in simplied form as Figure 6.4. 6.2.4 Determination of the First Half-Value Layer, HVL1

Mo 30 mm Mo Mo 30 mm Mo Mo 30 mm Mo Mo 30 mm Mo Mo 30 mm Mo Mo 25 mm Rh Mo 25 mm Rh Mo 25 mm Rh Mo 25 mm Rh W 60 mm Mo W 60 mm Mo W 60 mm Mo W 60 mm Mo W 50 mm Rh W 50 mm Rh W 50 mm Rh W 50 mm Rh W 40 mm Pd W 40 mm Pd W 40 mm Pd W 40 mm Pd Rh 25 mm Rh Rh 25 mm Rh Rh 25 mm Rh Rh 25 mm Rh

25 28 30 31 34 22 25 28 34 22 25 28 30 22 25 28 30 22 25 28 30 23 25 28 30

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The maximum variation from the listed values are + 0.03 mm Al.

Direct measurement of the x-ray spectrum is possible, but not generally practical as a eld measurement because specialized equipment and careful geometric alignment is required to make reliable measurements. Routinely, the practical determination of x-ray beam quality relies on simple attenuation measurements, usually in aluminum for mammography x-ray energies, to determine the half-value layer. The rst half-value layer, HVL1, is the thickness of a specied material that attenuates the beam of radiation to an extent such that the radiation quantity is reduced to half its initial value (ICRU, 1970). The use of different radiation quantities such as exposure or absorbed dose will lead to different HVL1 values. For the characterization of x-ray beams used for mammography, the air kerma, Ka, or the air kerma rate, K a , is recommended for the determination of the HVL (ICRU, 2005). In the denition of HVL, the contribution of all scattered radiation, other than any that might be present initially in the beam concerned, is to be excluded. The half-value layer alone is often not an adequate specication of the x-ray beam quality because markedly different

spectra can sometimes result in the same value of HVL1 (ICRU, 2005). In the absence of full spectral characterization, a more complete description of the beam quality can be accomplished by either specifying the tube kilovoltage or measuring the second HVL (HVL2) in addition to HVL1. Typical values of HVL1 for mammography are shown in Table 6.5. For a measurement of the HVL, the recommendations of the ICRU (1964) should be followed. A narrow beam and a sufciently large distance between the absorber and measuring instrument should be used to obtain the correct HVL. The instrument used for the attenuation measurements should have weak energy dependence over the range concerned. Modern x-ray equipment used in mammography produces highly reproducible radiation output from exposure to exposure. If it is suspected that this is not the case, a monitor can be used to facilitate a correction for variations of output. If used, such a monitor should be positioned so that its readings are independent of the thickness of the absorber. By limiting the


eld diameter, the amount of scattered radiation recorded will be reduced, but the eld dimensions must be larger than the sensitive volume of the measuring instrument. The collimator must be of sufcient thickness to absorb the primary beam. A radiographic method can be used to check the alignment of this aperture. 6.2.5 Determination of the Compressed-Breast Thickness

It is well known that the indication of compressed-breast thickness on mammography units is not always reliable because the compression plate can bend and deform considerably. Burch and Law (1995) have proposed a thickness measurement based on the imaging of lead markers placed on the compression plate and by calibration of the breast thickness on the imaged positions of the lead markers on the mammogram. Yang et al. (2003) have described an optical method based on the principle of stereoscopy for precise determination of the compressed-breast thickness. This method has been rened and simplied by Mawdsley et al. (2009) and by Tyson et al. (2009).

The secondary laboratories disseminate calibrations at specic radiation qualities appropriate for the use of the instrument and provide statements on the uncertainty of these calibrations. In many countries, the secondary laboratories provide expert services in dosimetry to end-users in hospitals and other institutions involved in applications of ionizing radiation. In some countries the secondary laboratories are specically accredited to provide this knowledge and calibration. An example of this is the Accredited Dosimetry Calibration Laboratories (ADCLs) in the USA. It is required that these laboratories possess a secondary standard calibrated at the primary laboratory, participate in comparisons, and be authorized (accredited) for this activity following the international standard ISO 17025 (ISO, 2005). A recent publication from the IAEA establishes a Code of Practice for diagnostic ionizing-radiation measurements in which mammography is included (IAEA, 2007). 6.3.1 Methodology of Chamber Calibrations

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Calibration and Characteristics of Dosimeters for Mammography

As discussed in Section 6.2, dose in mammography is generally estimated from a determination of air kerma at a location corresponding to the entrance surface of the breast. The air kerma is measured using an ionization chamber, which must have a calibration traceable to a primary laboratory. The primary laboratory establishes a mammography standard with the use of a free-air chamber (FAC). A FAC designed for mammography was described by Coletti et al. (1995) and has been adopted for its primary-standard instrument by the US National Institute of Standards and Technology (NIST). Comparisons of measurements with FACs from different national metrology institutes generally agree to within 0.5 %, which is within the limit of the uncertainty involved in the comparisons (Burns et al., 1999). Some primary laboratories calibrate the user chambers directly; however, it is generally impractical for them to calibrate the very large number of radiation dosimeters that are in use all over the world. Therefore, typically, the mammography standard is transferred to a secondary laboratory, which in turn calibrates the chambers that are used for measurements in the clinical setting.

All measuring equipment used in secondarylaboratory calibrations is generally of a reference class, and duplicate instrumentation is available to facilitate intercomparisons. This includes ionization chambers, electrometers, thermometers, barometers, and devices to measure the relative humidity of the air. For calibration purposes, the only detector that is considered to be a reference-class dosimeter is an ionization chamber. The primary advantage of ionization chambers is that they can be constructed in such a way that they exhibit only a small variation of response with varying radiation energy. Furthermore, they are known to have good long-term stability. The chamber is required to have a valid calibration traceable to a primary laboratory for the energy or energies at which the secondary calibration applies. Generally, calibrations are performed by the substitution technique whereby the laboratory reference chamber is used rst to determine the air kerma and this value is then transferred to the users chamber whose response is measured at the same position. 6.3.2 Considerations for Ionization Chambers Used for Measurements in the Field

Wagner et al. (1992) have given recommendations for calibration and use of ionization chambers. DeWerd and Wagner (1999) describe the characteristics of radiation detectors for mammography. The most common type of ionization chamber for mammography measurement of air kerma is a plane-parallel chamber. Plane-parallel ionization

Patient Dosimetry in Mammography

chambers (also known as parallel-plate chambers) use two parallel, at electrodes, separated by a few millimeters. They are calibrated with their plates oriented perpendicularly to the beam axis, which is also the orientation in which they should be used. Some of these chambers have entrance and exit windows of different compositions and thicknesses. In this case, it is important that the entrance window faces the x-ray source. In contrast, the response of cylindrical chambers is symmetrical with respect to the chamber axis. They are usually oriented with the cylindrical axis of the chamber perpendicular to the x-ray beam. Irrespective of their geometrical design, ionization chambers used in mammography should be of the vented type, i.e., their sensitive gas volume should be in equilibrium with the atmosphere. In the case of ionization chambers, it is also important to measure the temperature and pressure at the time and place of measurement. There are some dosimeters that measure temperature and pressure and automatically correct for their inuence. In such dosimeters, it is recommended that the performance of this correction be checked periodically to ensure that it is being applied properly. Also, the time interval between periodic calibrations of the reference instrument should be within the acceptable period dened by national regulations. Where no such regulations exist, the time interval should not exceed 2 years. Energy Dependence of Chambers. Various ionization chambers used for mammography can demonstrate a marked energy dependence. Wagner et al. (1992) considered a + 1 % variation to be the acceptable limit for such an energy dependence over the range of x-ray beams used for mammography (24 kV to 35 kV or HVL1 of 0.15 mm Al to 1.0 mm Al). A number of chambers and their response to different x-ray spectra maintained by the National Institute of Standards and Technology (NIST) were investigated (DeWerd et al., 2002). The molybdenum x-ray beams established at NIST are given in Table 6.6. The response of the chambers was determined using the primary-standard FAC (Coletti et al., 1995; 1997). The reference beam quality was chosen to be M30 (the standard tungsten-target mammography reference used before the establishment of the molybdenum beams). A comprehensive study of the effect of x-ray beam spectra on the response of mammography dosimeters (including both ionization chambers and other types of dosimeters) was done also within an EUROMET project (Witzani et al., 2004). Conclusions of this study were similar to those of DeWerd et al. (2002). A representative graph for

Table 6.6. Standard NIST x-ray spectra Beam codea Tube voltage (kV) Added lter (mm) First half-value layerb (mm Al)

Mo target Mo/Mo23 Mo/Mo25 Mo/Mo28 Mo/Mo30 Mo/Mo35 W target M30


23 25 28 30 35 30

0.032 Mo 0.032 Mo 0.032 Mo 0.032 Mo 0.032 Mo 0.50 Al

0.29 0.31 0.35 0.37 0.40 0.36

The mammography beam codes are a combination of the chemical symbols of the target and of the lter, respectively, followed by the (constant) tube potential in kV. b The maximum variation from the listed values is estimated to be about + 0.02 mm Al.

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Figure 6.5. Response for an ionization chamber with marked energy dependence.

Figure 6.6. Response for an ionization chamber with weak energy dependence.

a chamber with a fairly marked energy dependence is shown in Figure 6.5 and that for a chamber with only weak energy dependence for various targets and lters is shown in Figure 6.6. A range of responses with energy is given in Table 6.7.


Table 6.7. Measured energy responses of some commercial ionization chambers Chamber manufacturer Ratioa of response Mo28/M30 1.002 1.008 1.007 0.997 1.012 1.001 0.992 0.989 0.997 1.008 Energy response range (over entire mammographic region) 0.993 1.010 0.997 1.010 0.971 1.023 0.971 1.049 0.986 1.026 0.980 1.048 0.954 1.040 0.958 1.030 0.985 1.026 0.945 1.073

1 2 3 4 5 6 7 8 9 10

Ratios are given of the responses to the spectrum from an Mo target at 28 kV and to that from a W target at 30 kV.

The largest variation in energy response of the chambers characterized in Table 6.7 is 12 % for manufacturer 10. This particular chamber has two sides with different x-ray entrance windows, one for mammography and the other for general diagnostic applications. If the chamber is used in the wrong manner (diagnostic side toward the mammography beam), there can be a signicant error. Of the chambers designed to be used exclusively for mammography, the relative response varies from 2 5 % to 5 %. Effect of Energy Response on Ionization Chamber Measurements. Variation of response with energy can affect the results achieved with a chamber, both for HVL measurements and for the determination of the MGD. The MGD is dependent on the air kerma as well as on a variable related to the beam quality (HVL) as was discussed in Section 6.1.3. Measurements of HVLs were made with the chambers listed in Table 6.7 and these were compared with measurements performed with a FAC (DeWerd et al., 2002). The ratio of the HVL determined with the FAC versus that of those chambers ranged from 0.986 to 1.026, whereas for chambers having a very weak energy dependence the ratio was closer to 1.000. This energy response sensitivity in measurement of the HVL translates into a variation of the calculated MGD of from 1.2 % to 2.5 %. 6.3.3 Measurements with Thermoluminescent Dosimeter

Thermoluminescence has found great use in dosimetry. Thermoluminescent dosimeters (TLDs), based on a solid-state luminescence phenomenon,

are a convenient way to make a measurement on a patient or a phantom. TL dosimeters are available in various forms (e.g., powder, chips, rods, ribbons) and are made of various materials. Dosimeters most commonly used in medical applications are based on lithium uoride doped with magnesium and titanium (LiF:Mg,Ti) but other materials such as LiF:Mg,Cu,P, Li2B4O7:Mn, CaSO4:Dy, and CaF2:Mn have also been used. TLD measurements are especially useful for dose comparisons and have been incorporated into mammography accreditation programs (ACR, 1999). These dosimeters should not be used for a reference calibration, which should be performed with an ionization chamber. However, TLDs can be very useful to measure entrance air kerma for particular patients (DeWerd and Chiu, 1993) from which their MGD can be estimated. A portion of the energy absorbed in the TLD causes electrons to be excited and then trapped in metastable states in the crystal lattice. The trapped charges remain in the metastable states until they are re-excited and emit energy in the form of light. If the method of re-excitation is heat, then the process is called thermoluminescence. The amount of light emitted is proportional to the radiation absorbed in the material. Many factors inuence the result of a TL measurement, including those related to the performance of the instrument and those related to procedures of dosimeter preparation and handling. When calibrating the dosimeter, the whole system must be considered. A review of the application of a TL method for dosimetry in diagnostic radiology was published by Zoetelief et al. (2000). When TLDs are employed, it is important to pay particular attention to the processing of the material. For example, the annealing regimen, which is the method used to deplete the population of trapped charges or to change the trap structure to prepare the material for reuse, can affect the dose measurement. Generally, it is the higher temperature (deeper) traps that are useful for dosimetry purposes. Some TL materials have specied annealing regimens to eliminate low-temperature glow peaks without affecting the higher-temperature peak. This can be accomplished by a low-temperature preheating operation before reading, which causes charges to be released from low-temperature traps while having a negligible effect on charges in the high-temperature traps. Only well-established annealing cycles should be used; their reproducibility is important for accurate dosimetry. The trapped charges are also slowly released at room temperature. This process is called fading. Attention must be paid to situations in which

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Patient Dosimetry in Mammography

dosimeters are stored at higher temperatures. A correction for fading and/or high-temperature storage effects must be made when TL dosimeters are read long after irradiation. An extensive description of various TL materials and procedures for their preparation, handling, and evaluation can be found in the literature (Boetter-Jensen et al., 2003; Horowitz, 1984; McKeever et al., 1995). During read-out, the TL detector emits light in a quantity proportional to the energy deposited during irradiation. The electrical signal derived from the emitted light must be converted to one of the quantities of interest, generally entrance air kerma. This requires that the dosimeter be calibrated with a known source of radiation such as 137Cs with the subsequent application of a correction factor for the difference in response between the energy of the 137 Cs gamma rays and the x rays used in mammography. Alternatively, an established standard x-ray spectrum, such as at 30 kV, can be used.

simple to give a specic gure for the uncertainty of these measurements. Of necessity, the standard uncertainty of a calibration coefcient for TL dosimeters is higher than the uncertainty for the reference instrument, which is usually the ionization chamber. With special care, a value of 3 % is achievable for the relative combined standard uncertainty of a TL dosimeter calibration (DeWerd and Chiu, 1993). Additional sources of uncertainty come from various correction factors, such as the energy dependence of the TL dosimeter response, dosimeter fading, nonlinearity of response, and other parameters. Zoetelief et al. (2000) show an example of an uncertainty budget for TL measurements. Generally, the value of 12.5 % (1 standard deviation) can be assumed to be a reasonable estimate for the uncertainty, although 5 % is achievable with special care.

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6.4 Uncertainties in TL Measurements. Zoetelief et al. (2000) recommend that the TL measurements in diagnostic radiology be done with a relative combined standard uncertainty better than 12.5 %. As there are many factors that inuence measurements with TL dosimeters, it is not


Modern dosimetry instruments, both ionization chambers and TLDs, provide ample accuracy and precision for the dose estimation requirements of mammography. Improved accuracy in dose estimation is likely to come from more realistic models of tissue distributions in the breast.


Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


7. Measurement of Image Quality in Mammography

The quality of the mammogram is dependent on the interplay of many technical factors. To ensure high quality, each of these should be properly adjusted and once selected should be maintained over time. This implies measurement of certain technical parameters to attain proper setup of the system. Following this, periodic testing of the mammography system is required to ensure that performance does not deteriorate. The philosophy behind testing is to measure those factors that have a marked effect on image quality. The frequency of measurement should be based on the likelihood that a particular factor will change over time and the rate at which change can occur. Because testing requires valuable resources that might better be used elsewhere, it is important to focus on performing the tests that will be most informative, i.e., that will identify changes associated with degradation in image quality or that will predict such degradation. Testing can be classied as rigorous, detailed laboratory evaluations or as eld measurements. In the case of screen-lm technology, these two types of tests are generally quite distinct. For images recorded on lm, certain measurements such as those of the MTF and Wiener spectrum (WS) must be done in a laboratory if reliable results are to be obtained. As such, they can be invaluable in the optimization of component and system design, but are generally not of much use in the eld. Practical eld tests must be carried out with the realization that they might not be measuring the variable that ideally should be measured, but that they can be done quickly and reliably with relatively simple and portable equipment outside of a carefully controlled laboratory environment. Frequently, such tests can be somewhat subjective in naturethe reading of a resolution test pattern, for example. Of course, the eld test must measure a variable that is at least indirectly relevant to image quality if the test is to be of any value. Because the digital mammography detector provides linear or logarithmic recording of the transmitted x-ray uence in numerical form, with digital systems it is often possible to carry out a more quantitative eld test that is a reasonable surrogate for the rigorous laboratory method. Examples are measurements of the modulation transfer function (Section 7.4.5) and the WS (or noise-power spectrum; see Section 7.5.7), both of which become practical on digital mammography systems.

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Technical versus Clinical Field Assessment

It is appropriate to consider the day-to-day assessment of clinical images and the routine eld evaluation of image quality as complementary rather than competing approaches for ongoing quality assurance. The subjective, qualitative judgments rendered by experienced observers should be given considerable weight. Nevertheless, measurements made under reproducible circumstances will often unambiguously identify trends not reliably detected by the clinical observer. In addition, objectively measured image-quality parameters usually facilitate the interpretation of the radiologists comments and subsequent system modications or repairs. Thus, the radiologists subjective assessments of mammographic image quality and objective physical measurements should be considered together. For the technical aspects of image quality, performance can be quantied objectively, especially when the images are obtained in digital form.


Mammographic Phantoms and Test Objects

A mammographic phantom is a device that can be used to simulate one or more of the radiographic tasks involved in imaging the breast. It is radiographed in a manner similar to that in which the breast would be imaged, and the resultant test image is evaluated. Phantoms can be used for many purposes, including subjective overall assessment of image quality and quantitative measures of parameters related to image quality (e.g., spatial resolution). Further, phantoms can be used for comparison of equipment for consideration of purchase,

# International Commission on Radiation Units and Measurements 2009


acceptance testing, attempts to optimize equipment adjustment or imaging technique, problem solving, and routine quality control. A mammographic phantom should possess as many of the following properties as possible: (1) It should have unvarying imaging characteristics over time so that any change in the radiograph of the phantom is due to the imaging system. (2) It should provide a meaningful subjective indication of image quality. (3) It should be able to be used to generate objective and quantitative measures of image quality. A test object is a device used to perform an objective or quantitative measurement of some aspect(s) of the mammography system. Frequently such objects are similar to those used for evaluating other types of radiographic systems. Some currently available mammographic phantoms and test objects are described in Appendix B. 7.3 Sensitivity and Contrast

Figure 7.1. Radiograph of a simple contrast test tool for QC. For digital mammography systems, quantitative noise assessments can be performed using this tool. Here, s1 and s2 are the mean digital signal values for the regions of interest shown, and the ss represent the corresponding standard deviations in the signals.

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Both sensitivity and contrast can be evaluated in terms of overall system performance. Alternatively, and to provide a better understanding of the performance of the subsystems and to help isolate problems, the aspects of sensitivity and contrast can often be broken down into subsystems. For example, radiation contrast and display contrast can be measured separately. Measurements of contrast should be accompanied by considerations of the latitude performance of the imaging system.

attenuation of a 4.5 cm 50/50 breast) is convenient for this purpose. The OD of the processed image is then measured with a densitometer. A target OD in the range 1.6 OD to 1.85 OD provides excellent contrast on current mammography lm. When this test object is imaged using either manual or automaticexposure-controlled techniques, the resultant OD can be measured with a densitometer. If it falls outside the acceptable range, the x-ray unit should be adjusted to provide this OD on a consistent basis.


Measurement of Overall Contrast


Target Optical Density and Exposure

In lm mammography, it is very important, for several reasons, for the lm to be exposed and processed to yield the proper optical density (OD). The gradient of the lm, and therefore the display contrast, depends on OD and for this reason it is important to image as much of the important breast anatomy as possible in the steep region of the characteristic curve. In addition, the image signal-to-noise ratio (SNR) depends on the amount of radiation contributing to the image, and this is reected by the OD. Although OD will vary continuously through the image, a target value can be set by imaging a test object that is simply a uniform slab of plastic such as polymethyl methacrylate (PMMA). This should provide x-ray attenuation comparable to that of the average breast. A thickness of 4.0 cm (which is representative of the

For mammography quality control, a measurement of overall contrast can be obtained by imaging a step wedge that provides a set of attenuation levels extending over the range of exposures the image receptor would receive. While not a rigorous measurement of contrast, this provides a very good measure of the stability of contrast of the entire system over time. Alternatively, a simple test object consisting of a 4.0 cm thick slab of PMMA can be imaged. A small 1 mm thick PMMA disk is placed over the slab to provide positive contrast, or a 1 mm deep at-bottom hole can be milled in the central area to provide a single contrast step. The former is more representative of lesions in the breast but is slightly more difcult to use in practice because the disc can become detached and lost, or if glued can result in artifacts. The image of such an object is depicted in Figure 7.1. An alternative object is a 0.2 mm thick disc or square of aluminum, as used in the European protocol for digital mammography (Van Engen et al., 2006). The contrast index is simply the difference in signal or OD between the image of the background adjacent to the disk and the image of the disk.

Measurement of Image Quality in Mammography

susceptibility to drifting of variables affecting lm processing, a sensitometric test should be performed on each day the processor is used. It is also useful to test the sensitivity every time a new batch of lm is started to monitor any inherent variations in emulsion sensitivity in order to separate this effect from those due to lm processing. This is known as crossover testing. Display Contrast. An index of display contrast can be derived by calculating the difference in OD between two xed steps on the sensitometry strip. One of the steps should provide an OD above the target OD; the other step should provide an OD below the target OD step. This is an index of gradient of the lm near the target operating point, which is a good measure of the display contrast. Changes over time in this value are indicative of variations in the emulsion or processing. A more complete and more dynamic description of lm gradient is to plot the derivative of the sensitometric curve over the complete range of exposures as in Figure 5.7. This provides the gradient at each exposure level and gives a good picture of the latitude of the image receptor. Two other valuable measures are the base plus fog density, which is the OD for the step where no light exposure was given to the lm by the sensitometer, and ODmax, the maximum OD under the highest-exposure step. The rst gives an idea of the response of the lm at the lowest exposures and can also indicate if the lm has become fogged due to excessive age, improper storage, or unintentional exposure to light or ionizing radiation. Note, however, that the recommended test for darkroom fogging of lm (as described in ACR, 1999) is much more sensitive and involves pre-exposure of the test lm. The maximum density provides a measure of the silver content of the emulsion and indicates if the lm has been fully developed. Procedures for carrying out sensitometric evaluation and suggested variances to initiate remedial action are given in Hendrick et al. (1999). Sensitivity in Digital Mammography. In a digital system it is possible to produce an image of arbitrary brightness at virtually any radiation level. Therefore, an index relating the radiation-exposure level to the digital signal is very useful as a check to ensure that the system is operating in a stable manner. Furthermore, when this relationship is known it provides a simple index for the radiographer to use as a surrogate for dose. If in normal clinical operation it is found that the signal level has changed, the cause should be determined. Naturally, one expects there to be

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Figure 7.2. Illustrative plot of results of lm sensitometry test. Film Tests of Display Sensitivity and Contrast. For lm mammography, the standard test for display contrast is by sensitometry and densitometry. A sensitometer is used to expose the radiographic lm to a set of calibrated light exposures spanning the range that would be encountered from the uorescent screen during mammography. Frequently the steps vary in transmission of light by a factor of 220.5. The lm is then processed, and the resultant ODs on the lm are measured using a densitometer. A graph of OD versus log relative light exposure is then plotted as in Figure 7.2. This is the characteristic curve of the sub-system comprised of the lm and the lm processing. If a sensitometer cannot be obtained, a set of x-ray attenuation steps can be used to provide an image similar to that from a sensitometer. The result is a sort of radiographic characteristic curve, but does not allow the effects of radiation contrast and display contrast to be isolated. Display Sensitivity. Display sensitivity for lm mammography can be quantied from the characteristic curve by selecting a reference exposure step from the sensitometric pattern that provides a target OD for the image. The OD for this step can then be tracked on a daily basis as a measure of sensitivity or speed of the lm/processing combination. Variations from the target OD by more than a pre-determined amount can be indicative of changes in the sensitivity of the lm emulsion or in processing variations due to one or more of the factors discussed in Section Because of the


some normal variability of the AEC system for different breasts, and this is not cause for concern. On the other hand, excessive variability can indicate a problem with the AEC or some other system that is giving rise to variation in patient dose. The sensitivity can be evaluated simply by imaging a standard test object under standard exposure conditions, measuring the dose to the object, and relating this to the signal level in a small region of interest (ROI) in the digital image of the object. Contrast in Digital Mammography. The factors affecting radiation contrast in digital mammography are essentially the same as those for screen-lm mammography. However, because display contrast can be arbitrarily adjusted by the user, measurement of radiation contrast is less important in digital mammography. Probably a more useful measure is signal-difference-to-noise ratio (SDNR), which is discussed later. Measurement of Radiation Contrast. In lm mammography, it is most practical to determine contrast from an image produced on lm. Radiation contrast can be inferred by measuring overall radiographic contrast (Section 7.3.2) and then working backward through the sensitometric curve of the lm (Section For digital mammography systems with linear digitization [all except Type 1 (see Section 4.2.1)], the test object depicted in Section 7.3.2 can be used to measure the difference between the disk and an adjacent region on the slab as s1 2 s2, where s1 is the digital signal value in the background and s2 is the value under the disk. The radiation contrast can be calculated in a manner analogous to Eq. (3.4) as C 2 Ds/(s1 s2).

these structures is too small to be detected by the human observer or because the difference in the two signal levels is comparable to the uctuation (noise) of the image, thereby preventing reliable perception. Thus, while it is often convenient to consider spatial resolution, noise, and contrast separately, it is important to realize that they are closely linked. Reading the image of the bar pattern provides a considerable amount of noise averaging because the eye tends to integrate along the bars. In addition, the eye responds to the edges of structures in a non-linear manner. By using a radial-spoke pattern in which the convergence of the alternating radio-lucent and radioopaque spokes toward the center of the pattern represent an increasing number of line-pairs per millimeter, it is also possible from a single image to measure limiting resolution in all orientations parallel to the image plane. For screen-lm mammography, the main factor affecting spatial resolution is the combination of the effective focal-spot size and the magnication factor. To measure overall spatial resolution in a clinical setting, the pattern is mounted parallel to the plane of the image receptor at a height 4.5 cm above the breast support surface. This provides a typical magnication encountered in imaging the breast. Because the pattern is of very high contrast, this is an optimistic estimate of the performance that would be possible when imaging the breast. At more realistic anatomic contrast levels, factors such as quantum noise and lm granularity will further impede the resolution of low-contrast structures. In some cases, it is possible to perform the test so as to isolate and quantify individual blurring effects. For example, to measure the resolution of the image receptor, the bar pattern can be xed rmly to the receptor so that there is negligible blurring due to motion or the focal-spot size. 7.4.2 Required Resolution

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7.4 7.4.1

Measurement of Spatial Resolution

Limiting Resolution

Spatial resolution of the image can be assessed in a simple, albeit subjective, way by imaging a pattern of evenly spaced radio-opaque bars (100 % contrast) and determining the greatest number of line-pairs (bars and spaces) per millimeter that can be resolved. Unsharpness in the imaging process will eventually make the bars and spaces blur together. This denes the limiting spatial resolution. While this measurement is thought of as one of spatial resolution, the reason that the bars fail to be resolved is that the unsharpness causes the contrast between the bars and spaces to become inadequate. In some cases, this is because the contrast between

Most mammographic screen-lm combinations provide spatial resolution (for high-contrast structures) of at least 20 cycles per millimeter, i.e., 20 lp/ mm. For the lower radiation contrast provided by the structures within the breast, the detectable resolution is lower because of quantum noise and granularity of the screen and lm. In order to achieve a balance between resolution limitations caused by geometric unsharpness and receptor blur, the ACR has recommended that the limiting resolution (for a high-contrast pattern) in a plane 4.5 cm above the image receptor, due to geometric factors, be no less than 13 lp/mm for bars parallel

Measurement of Image Quality in Mammography

to the anode cathode axis of the x-ray tube (normally the chest wall to nipple direction) and 11 lp/ mm in the perpendicular direction (ACR, 1999). 7.4.3 Point- and Line-Spread Functions, and Edge Response It is also possible to analyze the response of a radiological imaging system to an object simulating a perfect point, line, or edge. Points or lines can represent either an absorbing or transmitting structure. For example, a line object can be a ne, radio-opaque wire or a narrow slit allowing x rays to pass through. Blurring produced by the imaging system causes the image to be unsharp. A prole (in two dimensions) through the image of a point is referred to as the point-spread function. A prole in one dimension across the image of the line or edge is referred to as the line-spread function (LSF) or edge response (ER). Note that the LSF can be obtained by differentiating the ER. These spread functions provide a measure of spatial resolution: the greater the spread, the greater the degree of unsharpness. 7.4.4 Modulation-Transfer Function

Figure 7.3. Examples of the modulation transfer function (MTF) of mammography systems.

A more sophisticated measure of resolution is the modulation-transfer function (MTF), which describes the relationship between resolution and contrast in imaging patterns whose x-ray transmission varies sinusoidally with position (Rossmann, 1965). This is convenient because any radiologic transmission pattern can be described as a set of sinusoidal patterns of the appropriate amplitudes and spatial frequencies. Low spatial frequency corresponds to coarse detail, while higher frequencies are required to describe the ne details and edges of anatomical structures. In practice, the MTF can be determined in one dimension as the Fourier transform of the LSF (ICRU, 1986). Occasionally, it is easier to obtain the LSF by differentiating the measured trace of the signal in the edge response rather than by direct measurement. If the MTF is known, it is possible to predict exactly what the imaging system will do to the contrast and sharpness of a specic structure. The MTF (see Figure 7.3) describes the ability of an imaging system to transfer the modulation (analogous to contrast) of a structure to the nal recorded image. For example, a modulation transfer factor of 0.5 implies that the inherent modulation (contrast) of the object will decrease by 50 % because of limitations of the imaging system. If the contrast is low at the outset (say, 10 %), it will, in this case, be only 5 % in the recorded image.

As the spatial frequency increases (i.e., for ner detail), most imaging systems will transfer less of the incident contrast to the recorded image. At some point, the contrast becomes so low that it is imperceptible to the eye or lost in the noise. Limiting spatial resolution is sometimes expressed in terms of the frequency at which the MTF equals a certain value, e.g., the 4 % or 5 % level (Rossman, 1963), even though such a relationship is not precise. A major advantage of the MTF approach is that it can be used to analyze the performance of parts of a complex imaging system. Provided that the input and output image data are available for each sub-system, the MTF of that component can be determined. The overall MTF is the product of the MTFs of all sub-systems. This sort of analysis allows the weak link in a system to be identied and the overall system to be optimized. Determination of the MTF requires precise, highresolution digitization of the OD data on the lm. This requires a precision device such as a scanning microdensitometer, which is not normally available outside of research laboratories. MTFs of mammographic lm are generally measured only in specialized laboratories, and the spatial resolution of screen-lm systems in medical facilities are most commonly assessed by subjective inspection of images of bar or star patterns. 7.4.5 Spatial Resolution in Digital Mammography

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For the detector pitch of the current systems, it is expected that the useful MTF will extend to spatial frequencies of only from 5 cycles/mm (0.1 mm pitch) to 10 cycles/mm (0.05 mm pitch). The underlying hypothesis of digital mammography is that, despite its lower spatial resolution compared to screen-lm mammography, its improved SNR and the ability to enhance the displayed contrast for any region of the breast should provide


improved visualization of structures that are too subtle for screen-lm mammography to display or that are masked by dense tissue. The DMIST study (Pisano and Yaffe, 2005) has effectively conrmed this hypothesis. Measurement of the MTF in Digital Mammography. For digital mammography, it is practical to obtain an objective, quantitative measure of spatial resolution in terms of the MTF, derived from the Fourier transform of the LSF. One means of acquiring an LSF is to image a sharp edge of a metallic plate, such as that shown in Figure 7.4, producing an edge-spread function (ESF). A thin square of metal, with ground sharp edges, placed over a larger sheet of metal is inserted in the x-ray beam, parallel to the plane of the image receptor. This is imaged at a typical, clinically used kilovoltage setting with enough radiation to provide digital signal values in the normal range of clinical operation, but not high enough to saturate the detector nor low enough that quantum noise would be excessive. Differentiation of this ESF produces the LSF, which is then Fourier-transformed to obtain the MTF. Presampled MTF. In digital mammography systems, the image data samples obtained in recording the response to an edge are spaced one del apart. This introduces sampling error in characterizing the system. To overcome sampling error, the edge of the test object is tilted to a small angle with respect to the rows and columns of the dels. The data from multiple rows are then slightly offset. When they are combined by interleaving, they produce a much more highly sampled data set (see Figure 7.5) from which the pre-sampled MTF can be calculated (Dobbins, 1995). This essentially describes the underlying performance that the system would have been capable of before pixilation (sampling) takes place.

Figure 7.4. Test tool for measurement of MTF on digital mammography systems.

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For all types of noise measurements on digital systems, it is important to make measurements on the unprocessed image (the DICOM for processing image). Simple processing that corrects for variations in detector sensitivity and the heel effect (i.e., at-eld correction, see Section 4.3.1) are acceptable. However, some manufacturers attempt to correct for the MTF blurring due to the scintillator component in their detector, and this needs to be disabled for noise measurements. If this is not done, the noise measurement is likely to give results markedly different from the inherent noise properties of the system.


Standard Deviation

The simplest characterization of noise is in terms of the standard deviation of the number of x-ray quanta recorded in a given area of the image receptor or the standard deviation in image signal (OD or digital image value) over a given area of the image.


Measurement of Noise Properties

In order to measure noise characteristics in screen-lm mammography, it is generally considered necessary that the lm image in response to a uniform irradiation of the screen or uniform illumination of the lm be digitized. This normally requires a special irradiation geometry and use of a scanning microdensitometer for digitization. Therefore, quantitative noise measurements are seldom performed other than by lm manufacturers or in research laboratories.

Figure 7.5. Acquiring data for measurement of the presampled MTF. (a) Conventional sampling. (b) Oversampling. (c) Combining sampled data to create oversampled edge.

Measurement of Image Quality in Mammography


Wiener Spectrum

The noise in an imaging system is generally estimated from a discretely sampled array of image em; n, where the integers m and n signal data, a systematically index the sampling points. The tilde ( $ ) notation denotes that a is a random variable. The discrete WS of a discrete random variable is dened as Wd u; v lim

Nx !1 Ny !1

2 x0 y0 X em; ne2piumx0 vny0 ; Da Nx Ny m;n

7:1 where Nx and Ny are the number of pixels along the axes in the ROI, u and v are the spatial frequencies in the x and y directions, and x0 and y0 are the sampling pitches. The angled braces, k l, indicate averaging of multiple realizations of the spectrum (i.e., repeated experiments). More detail on practical measurement of WS is provided in Section 7.5.7 and in Maidment et al. (2003). 7.5.3 Signal-to-Noise Ratio

More important than the noise level itself is the consideration of the relative magnitudes of the noise and the useful image signal. This is described by the SNR of the image. 7.5.4 Noise-Equivalent Quanta

of the quality of information in the mammogram is the SDNR. For digital mammography, the same test object described in Section 7.3.2 can be used to measure the signal difference (SD) between the disk and an adjacent region of the same area on the slab as s1 2 s2, where s1 is the digital signal value in the background and s2 is the value under the disk (Bloomquist et al, 2006; Yaffe and Jong, 2003). In the European protocol for digital mammography, a 0.2 mm thick aluminum square, 20 mm on a side, is recommended for this purpose (Van Engen et al., 2006). It has been suggested more recently that the use of a smaller 10 mm 10 mm 0.2 mm Al test object, along with a relatively small ROI within the image of the test object, is preferable to minimize the contribution of the heel effect to noise measurements for systems that have not been at-eld corrected (Alsager et al., 2008). The noise in the signal difference can be deter2 1/2 , where s1 and s2 are the stanmined as (s2 1 s2) dard deviations of signal values in the two regions of interest. The radiation contrast can be calculated directly as Cs Ds/sav, where sav is the mean of s1 and s2. It is useful to analyze the SNR, the NEQ, or the SDNR versus spatial frequency (e.g., Figure 7.6) to describe the quality of the image for details of different sizes (Tapiovaara and Wagner, 1993; Wagner, 1999). 7.5.6 Detective-Quantum Efciency

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2 , is Often the square of the output SNR, SNRout calculated either at the nal output of the imaging system or at the output of some intermediate stage. In a system in which Poisson noise is the only noise source, this value is equal to the number of x-ray quanta that the imaging system has used to produce the image. In a system containing also one or more other noise sources, this value can be thought of as the number of quanta that the imaging system appears to be using to form 2 , is termed the the image. For this reason, SNRout number of noise-equivalent quanta or NEQ (ICRU, 1995). These measures can be thought of as describing the information content of the image. The higher the SNR or the NEQ, the more reliably subtle details in the image can be detected above the background noise.


Measurement of SDNR in a Digital Mammography System

In x-ray imaging, one is generally less interested in the absolute value of the signal than in the differences in signal between nearby points in the image. A convenient and useful descriptor

The efciency of the mammographic system in transferring information (in terms of SNR) from the x rays transmitted by the breast to the recorded or displayed image can be expressed as the ratio of the NEQ in the nal image to the number of quanta in the x-ray image at the entrance to the image receptor. This quantity is called the detectivequantum efciency (DQE) of the imaging system. Again, the DQE can be analyzed as a function of spatial frequency to give a more complete characterization of imaging performance (Bunch et al., 1987; ICRU, 1986; 2003; Shaw, 1963) (see Figure 7.7). Determination of the DQE requires three pieces of data: the MTF of the imaging system, its WS, and the number of x-ray quanta incident on the receptor. Note that the NEQ provides a measure of some aspects of the quality of the image, while the DQE characterizes the efciency of the imaging system in producing that quality. Currently, measurement of the MTF (see Section 7.4.4), the WS, the NEQ, and the DQE for screenlm systems requires a scanning microdensitometer to digitize the lms and is, therefore, done


Figure 7.7. Detective-quantum efciency (DQE) versus spatial frequency for a screen-lm mammography image receptor (curve a), a detector used for digital mammography (curve b).

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Figure 7.6. Noise-equivalent quanta (NEQ) plotted versus spatial frequency for a mammographic screen-lm system. Data are from Bunch (1999).

primarily in manufacturers laboratories. Because digital mammography systems provide data directly in digital form, it is much more straightforward to carry out these measurements in the eld and to incorporate them in routine quality-control programs. 7.5.7 Measurement of the WS in a Digital Mammography System

The availability of image data in direct digital form makes estimation of the WS, see Eq. (7.1), practical for digital mammography systems. The introduction of storage phosphors and computed radiography in the 1980s motivated clarication of the issues related to the WS of digital systems (Dobbins et al., 1995; Flynn and Samei, 1999; Giger et al., 1985). Storage phosphors are, in many ways, intermediate between analog systems and fully digital systems. In particular, the storage phosphor itself is an analog device, and under ideal circumstances would be a truly stationary device, while the read-out introduces discrete sampling. More recently introduced technologies such as atpanel devices are such that the discrete nature and spacing of the sample points are an intrinsic part of the detector. As digital detectors produce arrays of discretely spaced samples, and the sample spacing is generally not much smaller than the smallest objects of clinical interest, these detectors can no longer be considered strictly stationary. Thus, for an object of a size similar to or smaller than the spacing

between sample points, the detectability of such an object will in general vary if the object is moved by a fraction of the sample spacing. However, if the object is moved by an integer multiple of the sample spacing (along either axis), then ideally the detectability of the object should not change. A system is said to be cyclo-stationary if moving an integer multiple of the sample spacing does not change the expected recorded signal, and is said to be wide-sense cyclo-stationary if the second-order statistics do not change between two positions separated by an integer multiple of the sample spacing. Using this weaker condition one can develop a theory for digital detectors (Albert and Maidment, 2000; Cunningham, 2000; Gardner and Franks, 1975; Oppenheim et al., 1999; Papoulis, 1991) from several perspectives, which is in many ways analogous to the theory of detectors that demonstrate true stationarity. One conventionally works with nite regions and a discrete set of frequencies u k/Nxx0 and v l/Nyy0; thus, the sample WS, i.e., the WS of a single realization, is given by. 2 x0 y0 X 2pikm=Nx ln=Ny e em; ne Da W d k ; l : Nx Ny m;n 7:2 An estimate of the discrete WS can then be obtained by averaging N sample spectra:
N X e d;i k; l: ^ d k ; l 1 W W N i1


The discrete WS is dened for 0 k , Nx and 0 l , Ny. When interpreting values Nx/2 , k , Nx, corresponding to frequencies 1/(2x0) , u , 1/x0, it should be noted that the frequency u is an alias for u 2 1/x0. Similar remarks apply to v, l, and Ny.

Measurement of Image Quality in Mammography

The statistical uncertainty in the sample WS, q e d k ; l e cW Wd k; l, for a given frequency (u,v) is assuming Gaussian statistics, where c 1 if the Fourier basis function corresponding to [k,l ] has both real and imaginary components at the spatial sample points (as is generally true), and c 2 if this is not so (most signicantly for the zerofrequency component) (Blackman and Tukey, 1958; Cooley et al., 1967; Dainty and Shaw, 1974; Jenkins and Watts, 1969; Wagner and Sandrik, 1979). ^ d k; l, obtained by The estimated WS, W e averaging Wd k; l over N samples, will result in a q ~ d k; l. Assuming statistical uncertainty c=N W (as one does when performing Wiener-spectrum analysis) that the imaging system is wide-sense stationary1 and ergodic with respect to its noise properties, then these samples can be taken from either multiple images or multiple regions of the same image. Note that the statistical uncertainty is independent of the size of the region used; increasing the size of the region increases the spectral resolution but does not change the statistical uncertainty. Thus, in the calculation of the WS, one has the option of dividing a ROI into multiple smaller regions and then averaging the spectra calculated for each of the smaller regions. Equivalently, one can also smooth a WS by performing averages over spatial-frequency bins. Both procedures will similarly decrease the statistical uncertainty in the WS, but at the expense of decreased spectral resolution. With lm, it is conventional to produce a onedimensional slice through the actual twodimensional WS, Wt, by scanning the sample with a long, narrow slit. This procedure requires that the measured WS, Wm, be corrected for the nite width and length of the slit using ^ t u; v 0 Wm u W L ; sin c2 Au 7:4

where L is the length of the slit and A is its width. In mammography, the WS should be calculated from images acquired at a clinically relevant kilovoltage and beam quality. For laboratory measurements of the WS, well-dened x-ray spectra for mammography beams such as the IEC RQN-M or RQB-M spectra should be used (Bendat and

Piersol, 1986; IEC, 2005). An area of approximately 100 mm 100 mm located centrally should be used for determination of the WS. The ROI used to calculate a single spectrum should be np pixels by np pixels, where np 128, 256, or 512. The WS should be calculated for a range of air kerma at the detector entrance bracketing that normally seen in mammography, namely 1 mGy, 10 mGy, 100 mGy, and 1000 mGy (corresponding to exposures of approximately 0.1 mR, 1 mR, 10 mR, and 100 mR, respectively). WS-measurement conditions are determined by the intended purpose of the WS. For use in the calculation of the DQE, the IEC standard should be followed (IEC, 1994). The use of a grid in WS measurements will also depend upon the intended use of the WS. Normally, it is the WS of the detector that is of interest; thus the images should be acquired in a scatter-free geometry (as in RQN-M x-ray spectrum) without a grid, albeit at the normal operating distance. This normally requires that attenuating material be placed near the tube port such that a large air gap exists (see Section Unless explicitly described, all image processing should be deactivated except for processing required to linearize the image and to correct for malfunctioning detector elements. If the WS is being reported as a measure of the overall uctuations that could affect the quality of a clinical image, the RQB-M x-ray spectrum and geometry should be used. Image corrections should be made in the same manner as in clinical practice. In this instance, it is essential that images are processed as viewed. Various sources of minor variability in image signal between acquisitions (e.g., small variations in x-ray output) that are too small to be of clinical signicance can, however, inuence the WS calculation, particularly at low spatial frequencies. Attempts to correct this include rescaling so that the average value in all detector elements over a large region (greater than twice the linear dimensions of the ROIs) is the same in all images. However, the use of common-mode rejection (i.e., the pixel-wise subtraction of image pairs) should not be used when reporting clinically relevant WS. 7.5.8 Effect of Spatial Resolution and X-Ray Spectrum on Noise

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Note that for discretely sampled data, wide-sense cyclo-stationarity is required; namely, the mean and standard deviation are invariant to shifts in integer multiples of the pixel spacing.

Spreading of light in the screen blurs the recording of quantum noise, so that it becomes less apparent, but it also causes a decrease in spatial resolution. Higher-energy x rays will be absorbed with lower quantum-detection efciency, resulting


in a noisier image for a given number of x rays transmitted through the breast. Additionally, higher-energy x rays that interact with the phosphor produce a greater number of light photons per absorbed x-ray quantum, so that the required OD on a lm can be achieved with fewer x-ray quanta resulting in higher noise. In screen-lm mammography, quantum mottle might not be the dominant factor governing noise because of the high quantum-detection efciency (approximately 70 % to 80 %) of the screen, low average energy of the photons, and the relatively low light emission in the screen (Barnes, 1982; Nishikawa and Yaffe, 1985). In many cases, screen structural noise, variation in the amount of light produced per x-ray, and lm granularity (due to the random distribution of the nite number of developed silver halide grains) are major noise sources. Film granularity is generally the dominant noise source at spatial frequencies higher than a few cycles per millimeter (Bunch, 1997). The graphs of the NEQ (see Figure 7.6) and the DQE (see Figure 7.7) for the screen-lm system can be quite instructive in indicating where further improvements might be made. The example in Figure 7.7 indicates that the maximum DQE is only 35 % to 40 %, suggesting that there is room for at least a 2.5-fold increase in radiation detection efciency of screen-lm systems or an opportunity to produce images of higher information content without an increase in dose. This might be achieved with the use of ner-grained lm, screens of ner structure, and phosphors that produce a more constant amount of light for each absorbed x-ray quantum. It is also evident from these gures that performance falls off in regions of the characteristic curve in which the lm gradient is below its maximum value. This suggests that image quality might be improved by designing lms with characteristic curves providing a greater range over which the gradient is near maximal. Higher-speed mammographic screen-lm combinations resulting in reduced absorbed dose can be obtained by using a either a higher-speed screen or high-speed lm. Assuming all other factors are optimized, high-speed systems are generally less sharp or present more noise than images produced using a conventional lower-speed screen-lm emulsion combination. For any radiographic imaging system, including digital mammography, quantum noise is a fundamental factor that can never be eliminated, only minimized. This is accomplished by attempting to maximize quantum-detection efciency and by using an adequate absorbed dose. In screen-lm mammography, for a specied screen and lm the

amount of radiation used is largely determined by the need to achieve a given OD. 7.5.9 Contrast-Detail Measurements

Another method of assessing image quality in mammography is contrast-detail measurement (Loo et al., 1983). In this type of measurement, a test pattern containing a set of structures, usually circular discs, covering a range of diameters (detail) and providing a range of radiation contrasts, is imaged (Ramsdale 1989; Thijssen et al, 2001; Thompson and Faulkner, 1991). The images are typically viewed by observers who determine which of the test structures are visible. From such data, contrast-detail (threshold contrast-detail detectability) diagrams are generated. Such curves, plotting threshold contrast against size, provide a measure of overall performance. Threshold contrast is assessed by measuring the lowest detectable contrast of circular detail as a function of the detail area or diameter. Threshold contrast is affected by various factors including the sensitivity of the imaging system, structural and random noise, the presence of scattered radiation, and image unsharpness. Threshold contrast is also affected by the subjective judgment of threshold level by the observer for the visibility of patterns (Loo et al., 1984). A suitable test object for measuring threshold contrast must have disc sizes and a contrast range appropriate for mammography. Test objects with suitable contrasts and detail sizes include the TOR(MAX) (Cowen and Coleman, 1990) and the CDMAM (Thijssen et al., 2001). It is important that the contrast difference among the different details is ne enough, and that the range of detail sizes extends to a size comparable to the smallest clinically detectable details (e.g., down to about 100 mm) to adequately test the imaging system. Threshold-contrast results for typical digital mammography systems (CR and DR) using the CDMAM are shown in Table 7.1. Data for both analog and digital systems are presented as a contrast-detail diagram in Figure 7.8. In conducting contrast-detail tests, it is important to maintain a strict scoring protocol, i.e., either require the observer to work at a xed distance from the image or allow them to vary the distance at will, and to maintain constant threshold criteria for observers who will determine the threshold contrast. Alternatively, the threshold detectable radiation contrast can be assessed for specied detail sizes that relate to clinically signicant details. For screen/lm mammography systems, the National Health Service Breast Screening Programme in the

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Measurement of Image Quality in Mammography

Table 7.1 Minimum and achievable relative threshold contrast for digital mammography versus disc diameter in the European protocol for digital mammography Diameter of detail Relative threshold contrasta Achievable value 5 mm 2 mm 1 mm 0.5 mm 0.25 mm 0.1 mm , 0.4 % , 0.56 % , 0.85 % , 1.6 % , 3.79 % , 15.8 % Minimum standard , 0.85 % , 1.03 % , 1.38 % , 2.35 % , 5.43 % , 23.0 %

a Threshold contrasts are given for objects calculated for an x-ray spectrum of 28 kV with Mo target and 30 mm Mo lter.

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UK uses detail sizes of 5 mm to 6 mm and of 0.5 mm, which should have relative threshold contrasts of better than 1 % and 5 %, respectively (Moore et al., 2005). One useful aspect of this approach to measuring image quality is that it allows one to compare analog and digital systems in a clinically realistic simulation. It is used in the European protocol for

Figure 7.8. Contrast-detail diagrams typical of lm, CR, and DR mammography systems. Data on detection indices for typical analog and digital mammography systems using the CDMAM test object.

digital mammography to dene minimum and achievable standards for digital mammography systems, as shown in Table 7.1.


Journal of the ICRU Vol 9 No 2 (2009) Report 82 Oxford University Press


8. Conclusions
Factors affecting image quality and patient dose in screen-lm and digital mammography have been discussed. Some proposed parameters for judging image quality and breast-exposure measurements and dose calculations relating to changes in image quality factors have been reviewed. It is important to remember that the goal in making a mammogram is to obtain as much diagnostic information as possible at the lowest dose compatible with that information. As noted earlier, this necessitates compromises, i.e., an optimization of factors that affect image quality. These factors include: beam quality, compression, imaging geometry, grids, receptor characteristics, processing of the lm or digital image, and display and viewing conditions. If this optimization is done correctly, a high-quality mammogram can be obtained at a reasonably low dose to the patient. The goal is not simply to use as low a dose as possible, because if this is done there is a large risk of degrading the performance of mammography in detecting or accurately characterizing small, node-negative cancers. The choice of appropriate equipment used for mammography is of critical importance in ensuring a high level of image quality at a reasonable dose. Furthermore, the equipment must be properly maintained and its performance monitored through a routine quality-control program, with appropriate action taken in the case of test results that fall outside of achievable or acceptable limits. Without minimizing the importance of the technology, the skill and attention of the radiographer and radiologist are probably the most signicant determinants of the diagnostic result. Therefore, their training and regular updating of knowledge and skill is essential if consistently high-quality mammography examination is to be achieved.

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# International Commission on Radiation Units and Measurements 2009