ACR 2018 DM QC Program

ACR 2018 Digital Mammography Quality Control
Program
Objectives
• Provide Overview of ACR DM 2018 QC Manual

• Review QC Hologic Related Testing for Medical
Physicist
• Review Hologic Related QC Testing for
Technologist
ACR 2018 Digital Mammography Quality Control Program Internal Use Only 2
Quality Control: Why Is It Important?
• Ensure Dose to Patient is not Excessive

• Insure Adequate, Consistent Image Quality
• Detect Potential Issues Prior to Affecting Patient Care
ACR 2018 DM QC Manual
• 2nd Edition Published November 19,

2018
• The 2nd Edition now includes QC
testing for Digital Breast
Tomosynthesis (DBT)
• No hardcopy version sold. It can be
purchased and downloaded at the
ACR store:
https://shop.acr.org/Default.aspx?Tab
ID=55&ProductId=730400133
2018 ACR DM QC Manual
Purpose Use
• Standardized QC Testing for all • Can Only Be Used for Sites Performing Standard
2D and DBT Exams Only.
Manufacturers that are Clinically
Relevant • No Contrast Enhancement – If the site uses I-
View, they must use Hologic’s QC Manual for
• Standardized Test Frequencies all QC Testing
• The customer in consultation with their Medical

• Standardized Performance Criteria Physicist will decide which QC Manual to use with
each unit
o Cannot Mix and Match ACR and Hologic QC

Testing on one unit
• Requires Site to Purchase

New ACR Phantom
ACR 2018 DM QC Tests – Medical Physicist
Testing is broken down in three

categories:
o MEE
o Annual
o Troubleshooting
Resolution time varies by type:

o Critical - Before Clinical Use
o Non-Critical – 30 Days
Changes from ACR 2016 QC Manual are Highlighted in Yellow
Medical Equipment Evaluation (MEE)
• To Verify System Meets • Verify System • Visual Indication of Use • For Flat Paddles, Chest
Section 900.12(b) of Anchoring of Large or Small Focal Wall Edge shall be
FDA’s Final Rule for Spot (Pre and Post Straight and Parallel to
Mammography • Can Recover from Exposure) the Edge of the Image
Power Interruption Receptor and not
• To Comply with MEE- • Visual Indication of deflect more than 1cm
Only Required Tests • Grid is Out for Target Material Used when compressed.
Magnification (Pre and Post
Procedures Exposure) • Manual Selection of
mAs
• Magnification Value is • Compression Device
Between 1.4 to 2.0 • Manual Technique
• Power and Fine Factors shall be
• Collimator Light Output Adjustments displayed prior to
is Minimum 160 Lux making an exposure
(15 Foot-Candles) at • Compression Paddles
100 cm or maximum – Sizes and Special • AEC Technique Factors
SID (whichever is less) Purpose Displayed after the
Exposure has been
Made
ACR DM Phantom Image Quality
• To Verify Image Acquisition 18 Test Objects Present • Images shall be taken for both 2D • CNR and SNR - 2D Only
Chain is Providing and DBT. (If DBT is installed) The • Measurements are Made
Consistent Image Quality • 6 Fibers Window Width (WW) and Window Manually
Level (WL) settings shall be • SNR ≥ 40.0
• 6 Speck Groups optimized for visualization and • CNR ≥ 2.0
• To Verify No Clinically recorded for future evaluations. • CNR to be ≥ 85% of
Significant Artifacts Exist • 6 Masses Previous Year’s CNR
for both 2D and DBT • Minimum Score of 2 Fibers, 3 • Distance Measurement - 2D and
modes. Speck Groups, and 2 Masses DBT
Required for 2D and DBT images.
• Use Capture App Digital Ruler
The DBT image is scored using the
• To Verify that SNR and slice in which the test objects are
to Verify Phantom Width
CNR Values are Adequate best visualized. • 70.0 mm ± 14.0 mm
DBT Z-Resolution (New for 2018 QC Manual)
• Test to ensure blurring in the z-direction

is not excessive
• Physicist will use DBT ACR Phantom

image and take the sharpest image
along with 2 consecutive slices in each
direction and measure the maximum
signal value in each speck of the largest
speck group along with the background
signal to determine Full Width at Half
Maximum (FWHM) for Z-Resolution
DBT Z-Resolution (cont.)
• A baseline FWHM is determined at

installation that is to be used to compare
on future Medical Equipment
Evaluations (MEEs)
• The FWHM measured on future MEEs

must be within ± 30% of the baseline
value
• Failures must be corrected within 30

days.
Spatial Resolution
• Spatial Resolution Measurement done

with Line Pair Phantom at 45° Angle at
Manual Technique closest to ACR
Phantom
• SR ≥ 4.0 lp/mm – Large Focal Spot – 2D
• SR ≥ 4.0 lp/mm – Small Focal Spot – 2D
• SR ≥ 2.0 lp/mm – Large Focal Spot – DBT
• Failures must corrected within 30 days
DBT Volume Coverage
(New for 2018 QC Manual)
• Test to assure that the entire breast volume
is imaged during DBT acquisition
• Two 0.1 mm sheets of aluminum are

placed above and below the ACR DM
Phantom as shown.
• The closest manual DBT technique to the

ACR DM Phantom is used to make an DBT
image using the largest paddle.
DBT Volume Coverage (cont.)
• Verify that the slices for the top and

bottom sheets of aluminum are well
defined and in focus in their respective
planes.
• Failures must be corrected before

clinical use.
Slice for Top Sheet
AEC Performance
• Verify AEC Performance for 2D and DBT

with 2 cm, 4 cm, and 6 cm of BR-12
Material. Record Technique and
determine SNR
• Perform 2D exposure with Mag Stand

and 4 cm of BR-12 Material
• Pass/Fail Criteria:
• 4 cm SNR ≥ 40
• All SNRs must within 15% of previous year’s

values.
• Failures must be corrected within 30

Days
Average Glandular Dose (AGD)
• Measure Entrance Exposure for Average

Patient
• Determine HVL and Dose at Technique

for ACR Phantom for 2D and DBT to
Calculate AGD.
• Place Dosimeter Under Paddle at ACR

Phantom Height of 4.2 cm.
• AGD ≤ 3.0 - Failure must be Corrected
Immediately
• If available, Unit-Indicated AGD must be within

25% of Calculated AGD. - Failure must be
corrected within 30 days
Unit Checklist
• To Ensure all Locks, Detents, Indicators, and Mechanical Support

Devices for the X-Ray Tube and Breast Support Assembly are
Operating Correctly
• Verify DICOM Image File Headers are Correctly Populated
• Critical Failures to be Corrected Immediately
• Non-Critical Failures to be Corrected Within 30 Days
AWS Monitor QC
• Verify Monitor is clean from anything that

may interfere with Clinical Information
• Verify Monitor Luminance, Luminance

Uniformity are Correct (If Available)
• Evaluate DICOM Grayscale Display

Function (GSDF) to verify it does not
deviate by more than 10% of the
targeted response (If Available)
• Verify Monitor meets Manufacture Specs

through Automated Testing
(If Available)
AWS Monitor QC
• Use of TG18-QC Pattern to Evaluate

Monitor
(If Available)
• Use of TG18-LN01 & TG18-LN18

Patterns to Measure Luminance
(If Available)
• Use of TG18-UNL80 Pattern to Measure

Uniformity (If Available)
Refer to TB-01364 - Setup of Barco

QAWeb on Dimensions/3Dimensions AWS
for further details
AWS Monitor QC
• Any large significant blemish that

interferes with the visualization or QC of
images is considered a failure and must
be corrected prior to clinical use
• Failure of Test Pattern Image Quality,

Luminance Check, Luminance
Uniformity, DICOM GSDF, or Monitor
Manufacturer Automated Test(s) must be
corrected within 30 days.
RWS Monitor QC
• Verify Monitor is clean from anything that may

interfere with Clinical Information
• Verify Monitor is Calibrated Correctly and

Brightness & Contrast Settings are Correct (If
Available)
• Verify Image Quality and No Artifacts Present
• Evaluate DICOM Grayscale Display Function

(GSDF) to verify it does not deviate by more
than 10% of the targeted response (If Available)

(If Available)
RWS Monitor QC
• Evaluate ACR DM Phantom Image for

Artifacts and Score it (2 Fibers, 3 Speck
Groups, 2 Masses Minimum)
• Use Measurement Tool to Measure

Distance Across Wax Insert (70mm ±
14mm)
• Evaluate Ambient Light In Reading

Room. (Typically 20 – 45 lux)
RWS Monitor QC
• Use of TG18-QC Pattern to Evaluate Monitor
• Use of TG18-LN01 & TG18-LN18 Patterns to

Measure Luminance
• Use of TG18-UNL80 Pattern to Measure

Uniformity
• Failures must Corrected Prior to Clinical Use
RWS Monitor QC
• Any large significant blemish that interferes

with the visualization or QC of images is
considered a failure and must be corrected
prior to clinical use
• Failure of ACR DM Phantom Evaluation and

Distance Measurement must be corrected
prior to clinical use
• Failure of Test Pattern Image Quality,

Luminance Check, Luminance Uniformity,
DICOM GSDF, or Monitor Manufacturer
Automated Test(s) must be corrected within
30 days.
RWS Monitor QC (Monthly)

Artifacts and Score it (2, 3, 2 Minimum)

Monitor (If Available)
• Type of Failure Determines if it is to be

Corrected Immediately or Within 30
Days

Artifacts and Score it (2 Fibers, 3 Speck
Groups, 2 Masses Minimum)

Monitor (If Available)
• Any large significant blemish that

interferes with the visualization or QC of
images is considered a failure and must
be corrected prior to clinical use
• Failure of ACR DM Phantom Evaluation

must be corrected prior to clinical use
• Failure of Test Pattern Image Quality or

Monitor Manufacturer Automated Test(s)
must be corrected within 30 days.
AWS Monitor QC (Monthly)
• Verify Monitor is clean from anything that may

interfere with Clinical Information
• Verify Monitor meets Manufacture Specs through

Automated Testing
(If Available)
• Use of TG18-QC Pattern to Evaluate Monitor

(If Available)
• Any large significant blemish that interferes with

the visualization or QC of images is considered a
failure and must be corrected prior to clinical use
• Failure of Test Pattern or Monitor Manufacturer

Automated Test(s) must be corrected within
30 days.
• Verify Monitor is clean from anything that

may interfere with Clinical Information
• Verify Image Quality and No Artifacts

Present

(If Available)
Manufacturer Calibrations (if applicable)
• To ensure the DBT system is calibrated

properly according to the manufacturer’s
recommendations
• Applicable if manufacturer’s
documentation includes routine
calibration(s)
• Unit must meet prescribed periodic

calibrations
• Failures must be corrected prior to

clinical use
Collimation Assessment
• 2D – To be performed on initial MEE,

relevant service or component
replacement
• DBT – To be performed on initial

MEE, annually and after relevant
service or component replacement
• Verify Light Field to Radiation Field

Alignment
• Sum of misalignments of opposite sides

is within 2% of SID (14 mm)
MEE or Troubleshooting – Collimation Assessment
• Verify X-ray to Image Receptor Alignment

• X-Ray should not extend beyond receptor on
any side by more than 2% of SID (14 mm)
• Maximum cutoff of -2% of SID (14 mm) on
Left and Right Sides
• Maximum cutoff of -4% of SID (28 mm) on
Anterior (Nipple)
• No Cutoff on Chest Wall Edge
• For MEEs, failures must be corrected prior to

clinical use
• For Troubleshooting, failures must be corrected

within 30 days
MEE or Troubleshooting – Beam Quality (HVL)
• Verify X-Ray Beam is Adequate for

Patient Dose, but not Excessive so
Contrast is Lost in the Image
• Determine HVL at Technique for ACR

Phantom.
• Dosimeter at ACR Phantom Height of

4.2 cm. Paddle Closest to X-Ray Tube
• Test is performed on all target/filter

combinations (including tomo)
• HVL ≥ kVp/100 - Failure must be corrected

before clinical use
MEE or Troubleshooting – kVp Accuracy & Reproducibility
• Make 3 Exposures at the Most Commonly Used kVp.
• Make 1 Exposure at the Lowest Clinically Used kVp that

can be Measured
• Make 1 Exposure at the Highest Clinically Used kVp

(includes tomo)
• Verify kVp is Accurate within

± 5% of Indicated kVp
• Verify Coefficient of Variation is ≤ 0.02
• For MEEs, failures must be corrected prior to clinical use
• For Troubleshooting, failures must be corrected within

30 days
Troubleshooting – Ghost Image Evaluation
• Verify latent images are not present on

current image that impacts usage.
• Make 1 AEC Exposure with ACR DM

Phantom covering half of detector (AEC
Cells to be covered)
• After 1 minute, make 1 Manual

Exposure closest to AEC exposure with
ACR Phantom covering entire detector
and 0.1 mm Al (10 cm x 10 cm) in center
of imaging field.
Troubleshooting – Ghost Image Evaluation
• Use ROI tool and measure mean signal

values in the raw version of the second image.
Calculate Ghosting Index
• S1 – Value over the uniform attenuator on the side
where the attenuator was present in the 1st image
• S2 - Value over the uniform attenuator plus the

aluminum square on the side where the attenuator
was present in the 1st image
• S3 - Value over the uniform attenuator plus the

aluminum square on the side where no attenuator
was present in the 1st image
• Ghosting Index must be less than ± 0.3
• Failures must be corrected prior to clinical use
MP Involvement in
Equipment
Adjustments,
Changes, or Repairs
ACR 2018 DM QC Tests - Technologist
• Frequency of Test Vary by Type

o Weekly
o Monthly
o Quarterly
o Semi-Annually
o As Needed – Optional
o Per Mftr. Recommendation
• Detector Calibration
• Resolution Time Varies by Type

o Critical - Before Clinical Use
o Non-Critical – 30 Days
ACR DM Phantom Image Quality (Weekly)
• To be performed on 2D and DBT Modes
• Verify No Clinically Significant Artifacts Exist
• Minimum Score of 2 Fibers, 3 Speck

Groups, and 2 Masses Required
• Failures to be corrected prior to clinical use.
Compression Thickness Verification (Monthly)
• Use Smallest Non-Flex Paddle Available

on an item 10 cm long x 10 cm wide (or
less) Measure height with ruler.
• With 10 – 15 lbs applied, verify accuracy

is within ± 5 mm of measured
• Failures to be corrected within 30 days
Visual Checklist (Monthly)
• *Cleaning solution available
• *Locks operate
• *Paddles and Breast support have no cracks
• Verify room and equipment are dust free
• Verify Indicators, and Collimator Light are working
• Cables are safely positioned
• C-Arm and Compression Assembly Travel is Smooth
• *Critical Failures to be Corrected Immediately
• Non-Critical Failures to be Corrected Within 30 Days
Compression Force Verification (Semi-Annually)
• Verify manually, that the compression

device can meet 25 lb. minimum
requirement.
• Verify using initial power drive mode,

that the compression is between
25 and 45 lbs.
• Verify compression device maintains

compression
• Failures to be corrected prior to clinical

use.
Manufacturer’s Detector Calibration (if applicable)
• Verify detector is calibrated properly

according to manufacturer’s
recommendations.
• Failures to be corrected prior to clinical use.
Repeat Analysis (Optional)
• To determine number and cause of

repeated mammogram images
• Repeat rate to be 2% or less, but 5% is

allowed if agreed to by Medical Physicist
and Radiologist.
• Source of problem should be identified

and corrected within 30 days.
Thank You

ACR 2018 DM QC Program

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ACR 2018 Digital Mammography Quality Control

• Provide Overview of ACR DM 2018 QC Manual

• Ensure Dose to Patient is not Excessive

• 2nd Edition Published November 19,

• The customer in consultation with their Medical

o Cannot Mix and Match ACR and Hologic QC

• Requires Site to Purchase

Testing is broken down in three

Resolution time varies by type:

Changes from ACR 2016 QC Manual are Highlighted in Yellow

• Test to ensure blurring in the z-direction

• Physicist will use DBT ACR Phantom

• A baseline FWHM is determined at

• The FWHM measured on future MEEs

• Failures must be corrected within 30

• Spatial Resolution Measurement done

• SR ≥ 4.0 lp/mm – Small Focal Spot – 2D

• SR ≥ 2.0 lp/mm – Large Focal Spot – DBT

• Failures must corrected within 30 days

• Two 0.1 mm sheets of aluminum are

• The closest manual DBT technique to the

• Verify that the slices for the top and

• Failures must be corrected before

Slice for Top Sheet

• Verify AEC Performance for 2D and DBT

• Perform 2D exposure with Mag Stand

• All SNRs must within 15% of previous year’s

• Failures must be corrected within 30

• Measure Entrance Exposure for Average

• Determine HVL and Dose at Technique

• Place Dosimeter Under Paddle at ACR

• If available, Unit-Indicated AGD must be within

• To Ensure all Locks, Detents, Indicators, and Mechanical Support

• Verify DICOM Image File Headers are Correctly Populated

• Critical Failures to be Corrected Immediately

• Non-Critical Failures to be Corrected Within 30 Days

• Verify Monitor is clean from anything that

• Verify Monitor Luminance, Luminance

• Evaluate DICOM Grayscale Display

• Verify Monitor meets Manufacture Specs

• Use of TG18-QC Pattern to Evaluate

• Use of TG18-LN01 & TG18-LN18

• Use of TG18-UNL80 Pattern to Measure

Refer to TB-01364 - Setup of Barco

• Any large significant blemish that

• Failure of Test Pattern Image Quality,

• Verify Monitor is clean from anything that may

• Verify Monitor is Calibrated Correctly and

• Verify Image Quality and No Artifacts Present

• Evaluate DICOM Grayscale Display Function

• Verify Monitor meets Manufacture Specs

• Evaluate ACR DM Phantom Image for

• Use Measurement Tool to Measure

• Evaluate Ambient Light In Reading

• Use of TG18-QC Pattern to Evaluate Monitor

• Use of TG18-LN01 & TG18-LN18 Patterns to

• Use of TG18-UNL80 Pattern to Measure

• Failures must Corrected Prior to Clinical Use

• Any large significant blemish that interferes

• Failure of ACR DM Phantom Evaluation and

• Failure of Test Pattern Image Quality,

• Evaluate ACR DM Phantom Image for

• Use of TG18-QC Pattern to Evaluate

• Type of Failure Determines if it is to be