Imaging Equipment

and Maintenance:
Radiology Imaging
Modalities
SY 2022 - 2023

• Conventional Mammography • Xeromammography •

Conventional Fluoroscopy • Cinefluoroscopy •

CABRITO, HANNAH GAY C.

2nd Year BSRT
Conventional Mammography
  A procedure that uses x-rays to take pictures of the inside of the breast and stores the
images on x-ray film. Conventional mammography may be used to check for breast
cancer and other changes in the breast, such as abnormal lumps, cysts, or calcifications
(calcium deposits). Also called film mammography.

Historical Development
 The history of mammography can be arbitrarily subdivided into three periods: The Age of
Pioneers, the Age of Technical Progress and the Modern Era.

The Age of Pioneers

 In 1913, Albert Salomon, a German Surgeon conducted a roentgen-histological study on
over 3,000 mastectomies comparing the macroscopic observations with microscopic
pathology. The first attempts to use radiography for the diagnosis of breast cancer did not
become more established until four decades later.

The Age of Technical Progress

 In 1930, Stafford L. Warren, a radiologist at Rochester Memorial Hospital, New York
reported the use of a stereoscopic technique for in vivo mammography in 199 patients
who then underwent surgery.
 In 1931, Walter Vogel reported a radiographic classification of benign breast lesions and
how they could be differentiated from carcinoma.
 In 1938, Jacob Gershon-Cohen and Albert Stricker published an article describing the
range of normal radiographic of the breast.
 In 1950, Gershon-Cohen emphasized the importance of high contrast images obtain
without screen and with collimation and compression.

Parts and function

Generator
 In mammography we are dealing with soft tissue breast.
 20-40 kvp of x-ray energy is required for good contrast
 Max Ma-200Ma
For homogeneous x-ray beam, HFG is required.
3-10kw tube rating
3-5lakh HU-heat rating loading capacity

Collimator/cones
 Cones are required for proper direction of x-ray beam, proper collimator, for rejecting
scatter radiation and protection of chest wall and lungs from unnecessary radiation.
 3 designs are currently used
 1. Fixed aperture
 2. A set interchangeable cones for various sizes of breast
 3. An internal set of collimating blades
 For magnification and spot compression studies, manually adjusted shutters allow x-ray
field to be more closely matched to the volume being imaged.

Anti-scattered grid
 The anti-scattered grid must be a moving grid
  Carbon fibers is the preferred interspace material
 Focused grid with a grid ratio of 3:1 or 5:1
 Grid frequencies of 30-40 lines/cm
 Use of such grid doesn’t compromise the spatial resolution but it does increase the patient
dose
 Use of 4:1 grid approximately double the patient dose as compare to non-grid contact
mammography
 A unique grid is developed specially for mammography high transmission cellular grid.
 It reduced the scattered radiation in two direction, HTC grid has a copper as a grid stripe
and air as a interspace, physical dimension grid ratio (3:8:1)

Compression devices
 Compression plate: flat surfaced plate used for uniform compression
 In conventional plate anterior portion of breast is not compressed properly
 Newer slanted SOFT paddles are now equal compression to all areas of the breast

Advantages
 Provides immobilization of the part during exposure
 Provides radiograph of uniform density
 Reduces geometric unsharpness due to closer object to IR distance
 Reduces scatter and improves contrast
 Reduces tissue overlap and improves resolution
 Enhances recognition of architectural distortion produced by tumors
Disadvantage – is only patient discomfort
Spot compression- it is used to magnify small area of breast for better visualization.
Amount of compression is between 25 and 40 pounds of pressure.

Image receptor

 Film screen combination

 Single coated film-screen combination is commonly used today (GALDOLINIUM
OXYSULPHITE) provide higher film contrast and require significantly lower radiation
exposure compared to direct exposure film
 Currently in mammography single emulsion film are used in combination with single
back screen.
 Mammographic cassette: these are dedicated cassette used for mammography
only(18X24/24X30cm)

Automatic exposure control

  Photo timers are design not only to measure x-ray intensity at image receptor but also for
x-ray quality
 Photo timers are also called AEC device. And it is place after the image receptor
 And consists of a single ionization chamber or an array of three or more semiconductors
diodes
 X-ray transmitted through the breast, anti-scatter grid (if present), and the image receptor
generate a signal in the detector.
 The signal is accumulated (integrated) and, when the accumulated signal reaches a preset
value, the exposure is terminated
 The preset value corresponds to a specified signal-to-noise ratio (SNR) in a digital
mammography unit or an acceptable optical density (OD) if a film-screen system is used.

How does it work

 Mammograms are done with a machine designed to look only at breast tissue. The
machine takes x-rays at lower doses than the x-rays done to look at other parts of the
body, like the lungs or bones. The mammogram machine has 2 plates that compress or
flatten the breast to spread the tissue apart. This gives a better-quality picture and allows
less radiation to be used.

enter the breast over the AEC detector with the nipple in profile if possible.
• Hold the implant back against the chest wall. Slowly apply compression to the anterior skin
surface, being careful not to allow the implant to slip under the compression paddle. As
compression continues, the implant should be seen bulging behind the compression paddle.
 • Apply compression until the anterior breast tissue is taut. Compared with the full-implant
projection, an additional ¾ to 2 inches (2 to 5 cm) of compression should be achieved with
the implant displaced.

• Instruct the patient to indicate whether the compression becomes uncomfortable.

• When full compression is achieved, move the AEC detector to the appropriate position and
instruct the patient to stop breathing.
• Make the exposure.

 Release breast compression immediately.

Machine Quality Assurance Procedures

mage detection and acquisition system All protocols reviewed recommend testing the X-ray
source (tube voltage and HVL) and the AEC system. AEC testing is one of the most important
procedures due to its direct impact on IQ and breast dose. It should consider the effects of
variations in object/attenuator thickness and radiation beam quality. Hendrick et al. compared
QC practices in 22 countries (affiliated with the International Breast Cancer Screening Network)
and concluded that this test that was performed in all countries.

Breast dose the recommended methodologies for breast dose estimation vary. Measurements
using test objects and breast phantoms are frequently recommended and more practical to
implement than measurements based on TLD techniques.

Dose assessment with a standard test object/phantom facilitates the comparison of different
mammographic techniques and the investigation of the impact of technical settings on breast
dose. Clinical dose assessment (using clinical exposure data) provide valuable information on the
clinical practice and considers the influence of breast thickness and composition on dose

Variations in dosimetry techniques in mammography may prevent a robust comparison of breast

dose in mammography between countries and between radiology also highlighted that national
protocols adopt different phantoms, optical densities, measurement points and conversion
factors, which make it difficult to compare the doses estimated with different protocols.

measured the impact of variations in experimental technique (e.g. positioning of the dosimeter,
compression plate in or out of the beam) on MGD values and found noticeable variations.
When the European protocol was used, the value of the MGD increased by 5 ± 2 % (total
variation 0–9 %) at clinical settings and by 9 ± 3 % (4–17 %) compared with the use of the
Nordic protocol [21]. The same authors also compared measurements with different dosimeters
(ionization chambers vs solid-state detectors). They concluded that HVL measurements can be
performed accurately with a sensitive solid-state detector and a collimated radiation field,
correcting for energy dependence.

This review showed variations in the conversion factors used in the estimation of breast dose (to
account for X-ray spectrum characteristics and breast composition) amongst the guidance
documents.

Zoetelief and Jansen [25] compared protocols for dosimetry in mammography and concluded
that the use of different radiation transport codes and different spectra could cause differences in
the conversion factor g by up to about 7 %. They also showed that inclusion of the compression
plate in the beam results in a 4.5 ± 1.5 % smaller g value for the same HVL. Also, when breast
thickness increases from 2 cm to 8 cm, the g value decreases by a factor of 4.

Tsai et al. [15] showed that the MGD calculated using Dance’s method is 9–21 % higher than
that using Wu’s method. Jamal et al. [24] also compared MGD per film considering eight
different studies using different protocols and conversion factors and found MGD values with
noticeable variations for a same breast thickness.

The MGD critically depends on the X-ray spectrum generated by the TF combination and tube
voltage used. Modern digital mammography systems offer innovative TF combinations (e.g.
W/Ag, W/Al) and new conversion factors have been developed [24, 26, 27]. The protocols
reviewed do not yet include the most recent published data.

Quality of the acquired image All guidance reviewed recommends performing low-contrast
threshold detection testing, breast lesion visualization (e.g. simulated in phantoms) and artefact
analysis. Compression force, image noise and spatial resolution testing are also recommended
with variations in the proposed methods and test materials.

The EC protocol recommends assessment of image quality of digital mammographic systems

using images produced with a specific low-contrast-detail test object (CDMAM), which is a
costly tool not readily available in all imaging departments. The UK/IPEM and ACR protocols
recommend alternative test objects to CDMAM, namely TOR (MAM) and the ACR
accreditation phantom, respectively. The choice of a suitable IQ phantom should take into
consideration the technology to be tested (screen-film of digital). Huda et al. [30] examined the
effectiveness of the ACR phantom to assess image quality in digital mammography and
concluded that it is unsatisfactory due to an inappropriate range and sensitivity to characterize
simulated breast lesions.
Variations in recommended test objects originate differences in reference/tolerance values (Table
7). The number and type of recommended IQ tests varied (between 1 and 9) as well as the
recommended methodologies. Examples of methods found in the guidance for rating IQ include
absolute, or relative, scales (e.g. five-step scale, 1 (worst) to 5 (best); two-step scale with 1
(criterion was fulfilled) and 0 (criterion was not fulfilled); four-step scale as designed by PGMI
scale (perfect, good, moderate and inadequate).

The guidance documents reviewed do not include recommendations on observer training for IQ
assessment. This could be useful to reduce inter-observer variability in the assessment of IQ.

Also, breast compression force is influenced by breast thickness and composition. However, no
recommendations are provided to promote the optimization of compression force according to
individual characteristics of the breast (compressibility, composition and thickness) [31, 32].
Maximum values for compression in mammography are recommended [7, 11, 33, 34].

The composition of breast tissue is an important issue because increased breast density is known
as a risk factor for developing breast cancer [35]. Nevertheless, in the reviewed QA guidance for
IQ assessment breast density was not used as a standard.

In 2011, an addendum to the EC protocol, containing guidance for clinical evaluation of

mammographic images, was published promoting harmonization in image quality analysis.
Clinical IQ assessment conducted by experienced radiologists is important because it considers
the effects of image processing which may directly affect the visibility of relevant features and
the subsequent diagnostic outcome.

Xeromammography

Historical Development

 Xeromammography dates back to the 1960s, when it was first developed by Dr.
Kenneth Johnson at the University of Texas Health Science Center. The technique
was initially used to diagnose breast cancer, but it was later found to be useful for
other applications, such as detecting benign lesions. In the 1970s, the US Food and
Drug Administration (FDA) approved xeromammography for use in screening for
breast cancer. In the 1980s, the technology was further improved and digital
xeromammography was developed, which allowed for higher resolution images of the
breast. This development led to increased accuracy in the diagnosis of breast cancer.
In the 1990s, the technology was further improved with the introduction of digital
breast tomosynthesis (DBT), which used 3D imaging to provide more detailed images
 of the breast. In the 2000s, computer-aided detection (CAD) was added to
xeromammography, which allowed for automated detection of suspicious lesions. The
technology has continued to evolve over the years and is now used to diagnose a
variety of breast diseases.
 The development of xeromammography began in the early 1960s when the first
prototype x-ray systems were developed. These early systems used film-based or
plate-based x-ray systems and were limited in the amount of detail they could capture.
The first commercial xeromammography systems were introduced in the late 1970s.
These systems revolutionized breast imaging by providing a much higher resolution
image than the film-based systems of the time.
 In the 1980s, digital x-ray systems began to emerge, leading to further advances in
xeromammography. Digital systems allowed for higher resolution images, as well as
improved image processing capabilities. This allowed for more accurate diagnosis of
breast diseases.
 In the 1990s, computer-aided detection (CAD) systems were developed, allowing for
automated detection of abnormalities in xeromammography images. This allowed for
earlier detection of breast cancer and other conditions.
 In the 2000s, new technologies such as digital breast tomosynthesis (DBT) and 3D
xeromammography were developed. These allowed for even higher resolution
images, as well as a more detailed view of the breast.
 Today, xeromammography is used in conjunction with new technologies such as MRI
and ultrasound in order to provide a more comprehensive view of the breast and to
help detect any abnormalities.

PARTS AND FUNCTION

Xeromammography is a type of mammography that uses a combination of X-ray and computed

tomography (CT) imaging to create three-dimensional images of the breast.

Parts:

1. X-ray source: The X-ray source emits X-rays that pass through the breast and are detected by an
imaging device.
2. Imaging device: The imaging device is typically a digital detector that converts X-rays into digital
images.
3. CT scanner: The CT scanner is used to create a three-dimensional image of the breast by combining
multiple X-ray images taken from different angles.

Function:
Xeromammography is used to detect, diagnose, and monitor breast cancer. It provides detailed images of
the breast and can detect smaller, more subtle tumors than regular mammograms. It also allows doctors to
identify areas of concern and biopsy them if necessary.

HOW DOES IT WORK?

Xeromammography is a type of imaging technique used to detect breast cancer. It uses a specialized
digital x-ray machine to create an image of the breast tissue. The machine is designed to take x-ray
images of the breast without the use of radiation. This makes the procedure safer and more comfortable
for the patient.

The x-ray machine works by sending a beam of x-rays through the breast. The x-rays are absorbed by the
tissue and the energy is converted into an electrical signal. The electrical signal is then processed by a
computer to create an image of the breast.

The image created by the x-ray machine is called a mammogram. It is a two-dimensional image that
shows details of the breast tissue, including any abnormalities or tumors. The image is then sent to a
radiologist for interpretation.

MACHINE QUALITY ASSURANCE PROCEDURES

1. Pre-Installation Quality Assurance: Prior to installation, xeromammography machines should be
inspected for any visible signs of damage. All components and accessories should be checked for
completeness and accuracy.

2. Installation Quality Assurance: Installation of the xeromammography machine should be done by a

qualified technician. All components and accessories should be tested and calibrated according to the
manufacturer’s specifications.

3. Pre-Use Quality Assurance: A pre-use safety and quality assurance check should be performed prior to
each use of the xeromammography machine. This includes a review of the patient history, proper
positioning of the patient and any necessary protective shielding.

4. Post-Exam Quality Assurance: A post-exam safety and quality assurance check should be performed
after each use of the xeromammography machine. This includes a review of the images, proper
positioning of the patient and any necessary protective shielding.

5. Regular Quality Assurance: Regular maintenance and quality assurance checks should be performed on
the xeromammography machine according to the manufacturer’s instructions. This includes a review of
all mechanical and electrical components, calibration tests and visual inspections of the equipment.

6. Data Quality Assurance: All images should be stored in accordance with the manufacturer’s
instructions and reviewed for accuracy and completeness. Any discrepancies should be reported to the
appropriate personnel.

7. Quality Assurance Reporting: Quality assurance reports should be generated on a regular basis and
reviewed by the appropriate personnel. Any discrepancies should be investigated and corrective measures
taken as necessary.

CONVENTIONAL FLUOROSCOPY

HISTORICAL DEVELOPMENT

Conventional fluoroscopy is a form of medical imaging that has been used for over a century. The earliest
form of fluoroscopy was developed by Wilhelm Conrad Roentgen in 1895 and was used to examine the
bones of the hand. In the following decades, fluoroscopy was used for a variety of medical applications,
including diagnosing fractures and helping to guide medical procedures.
In the 1930s and 1940s, advances in technology led to the development of the first “true” fluoroscopes,
which produced real-time images of the body. These devices were used to diagnose and treat a variety of
medical conditions, including heart and vascular diseases.
In the 1950s, advances in digital imaging technology allowed for the development of digital fluoroscopes,
which provided clearer and more detailed images than the traditional analog fluoroscopes. Digital
fluoroscopes are now the standard of care for many medical procedures.

In the past decade, advances in computer technology have led to the development of 3D fluoroscopy,
which allows for precise visualization of the anatomy in real time. This has revolutionized the diagnosis
and treatment of many medical conditions, particularly cardiology and interventional radiology.

Today, fluoroscopy remains an important imaging modality in the diagnosis and treatment of many
medical conditions. Its use is expected to continue to increase in the coming decades as newer imaging
technologies are developed.

PARTS AND FUNTION

Conventional fluoroscopy is a type of medical imaging that uses X-rays to create images of the inside of
the body. It is commonly used to diagnose conditions such as broken bones, hernias, and foreign objects
in the body.

Parts:

1. X-Ray Generator: This is the main source of the X-ray beam. It produces the X-ray photons that are
used to form the image.

2. X-Ray Tube: This is the device that actually emits the X-ray beam. It is typically composed of an X-ray
source, an anode, and a cathode.

3. Image Intensifier: This device is used to amplify the X-ray image and make it brighter. It is typically
composed of an electron gun, a target, and a phosphor screen.
4. C-Arm: This is the device that holds the X-ray tube and image intensifier and allows them to be rotated
around the patient.

5. Video Monitor: This is used to view the X-ray image.

Functions:

1. Diagnosis: The primary function of conventional fluoroscopy is to diagnose conditions such as broken
bones, hernias, and foreign objects in the body.

2. Guidance: Fluoroscopy can also be used to guide medical procedures such as biopsies, surgical
instrument placement, and catheter placement.

3. Monitoring: It can also be used to monitor the progress of treatments such as chemotherapy or radiation
therapy.

4. Interventions: Fluoroscopy can also be used to perform minimally invasive procedures such as
endovascular stent placement.

HOW DOES IT WORK?

Conventional fluoroscopy is a type of medical imaging that uses X-rays to produce real-time moving
images of the body. These images are displayed on a monitor, and the radiologist can manipulate the way
the images are seen, allowing them to better identify and diagnose medical problems. The basic
components of a conventional fluoroscopy system are the X-ray tube, beam-limiting device, image
intensifier and a monitor.

The X-ray tube is the source of the X-ray beam. It is composed of a cathode, anode, and an evacuated
glass envelope. The cathode is a filament that emits electrons when heated and the anode is a tungsten
target that absorbs the electrons, accelerating them and converting the electrical energy into X-ray energy.
The beam-limiting device, such as a collimator, is used to control the size and shape of the X-ray beam.
This ensures that only the necessary area of the body is exposed to the X-rays.

The image intensifier is a vacuum tube that amplifies the X-ray signal and converts it into a visible image.
It is composed of an input window, image intensifier tube, output window, and a monitor. The input
window is made of a material that is transparent to X-rays and captures the X-ray signal. The image
intensifier tube amplifies the signal and the output window projects the image onto the monitor, where it
can be viewed in real-time.
MACHINE QUALITY ASSURANCE PROCEDURES

1. Pre-use Check: Before each use, a qualified technician should check the fluoroscopy machine for
proper functioning. This should include checking the power supply, display monitor, image intensifier,
and console controls.

2. Image Quality Evaluation: Images should be evaluated for proper magnification, focus, resolution,
contrast, brightness, and other image quality parameters.

3. Dose Monitoring: Radiation doses should be monitored to ensure that they are within the acceptable
range and in accordance with regulatory requirements.

4. Maintenance: The fluoroscopy machine should be serviced, calibrated, and tested on a regular basis by
a qualified technician in accordance with the manufacturer’s specifications and guidelines.

5. Quality Assurance Records: All quality assurance records should be maintained in secure, protected
storage and should be reviewed periodically to ensure that the fluoroscopy machine is operating properly.

CINEFLUOROSCOPY

HISTORICAL DEVELOPMENT

The history of fluoroscopy dates back to 1895 when the first fluorescent screen was developed by
Thomas Alva Edison. This fluorescent screen was essentially a flat glass plate coated with a thin film of
calcium tungstate. When a high voltage was applied to the plate, it emitted a visible light, allowing the
user to view objects in the dark.

The development of the modern fluoroscope came about in the 1920s when radiologists began to use X-
ray images to diagnose medical conditions. Initially, the images were viewed on a fluorescent screen, but
in the 1930s, the first real-time fluoroscopy system was developed. This system used a combination of a
high voltage source, an X-ray source, and an intensifying screen to create an image of the internal organs
on a fluorescent screen. This technology has been further refined over the years and is now used routinely
in medical diagnosis.
Today, fluoroscopy is used to diagnose a wide range of medical conditions, including cancer,
cardiovascular disease, and bone fractures. It is also used in minimally invasive procedures such as
angioplasty, where it is used to visualize the interior of the blood vessels. In addition, fluoroscopy is
sometimes used to guide surgeons during complex operations.

PARTS AND FUNCTION

Cinefluoroscopy is an imaging technique that combines the use of X-ray radiation and rapid-sequence
imaging to create a moving image of internal body structures.

Parts:

1. X-ray Generator: This is the source of X-ray radiation used to create the images.

2. X-ray Tube: The X-ray tube is a vacuum-sealed container that houses the X-ray emitting source and
collimator.

3. Image Intensifier: This device amplifies the X-ray signal and converts it into an electronic signal that
can be displayed on a monitor.

4. Digital Detector: The digital detector captures the electronic signal from the image intensifier and
converts it into digital data.

5. Monitor: The monitor displays the digital data from the detector as a moving image of the internal body
structures.

Functions:
1. Create Images: Cinefluoroscopy uses X-ray radiation to create images of internal body structures.

2. Amplify Signals: The image intensifier amplifies the X-ray signal and converts it into an electronic
signal that can be displayed on a monitor.

3. Convert Images: The digital detector captures the electronic signal from the image intensifier and
converts it into digital data that can be displayed on the monitor.

4. Display Images: The monitor displays the digital data from the detector as a moving image of the
internal body structures.

HOW DOES IT WORK?

Cinefluoroscopy is a medical imaging technique that uses X-ray technology to capture live, moving
images of the body. It is used to diagnose and monitor a variety of medical conditions such as heart valve
problems and gastrointestinal disorders.

Cinefluoroscopy works by passing a continuous series of X-rays through the body, and capturing these
images on a digital imaging device. This imaging device can be a film camera, a digital camera, or a
digital fluoroscopy system. When the X-rays pass through the body, they interact with the tissues and
bone, and produce an image. The captured image is then displayed on a monitor, allowing the physician
to observe the structures and functions of the body in real-time.

Cinefluoroscopy produces images that are similar to those of a conventional X-ray, however they are
much more detailed and can be seen in motion. The images created by cinefluoroscopic are also higher in
contrast and resolution than those of a conventional X-ray. This allows the physician to observe the
body’s movement, as well as its anatomy.

MACHINE QUALITY ASSURANCE PROCEDURES

1. Ensure that all components of the equipment are in proper working condition.

2. Check for any damage or wear to the machine, cables and other components.
3. Test the machine for proper operation and performance.

4. Perform regular maintenance on the machine as per manufacturer’s guidelines.

5. Check for any loose connections or wires.

6. Ensure that all safety features are in good working order.

7. Test the image quality of the machine to make sure that it is up to standard.

8. Ensure that all the necessary software updates are applied to the machine.

9. Inspect the machine for any signs of corrosion or water damage.

10. Conduct regular tests on the machine to make sure it is in compliance with industry standards.