Volume 35, Issue 6, June 2008
Index of content:
- Practical Medical Physics: Room 352
- ACR Accreditation in Nuclear Medicine and PET — A Practical Guide
35(2008); http://dx.doi.org/10.1118/1.2962374View Description Hide Description
The American College of Radiology's (ACR) Nuclear Medicine and PET Accreditation Programs evaluate qualifications of personnel, equipment, image quality, and quality control measures. It is believed that these are primary factors that impact the quality of patient imaging. The ACR accreditation allows facilities to critique and improve their practices as part of their preparation for the accreditation evaluation process. The goals of the ACR Nuclear Medicine and PET Accreditation Programs are improvement in the quality of imaging, provision of educational information by raising awareness of imaging issues, and the recognition of imaging facilities which meet program objectives. This presentation will outline the program requirements, highlighting some of the common pitfalls that may cause deficiencies in both the clinical and phantom submissions.
1. General information describing the ACR Accreditation Programs.
2. Information about the Diagnostic Modality Accreditation Programs.
3. Specific information about the ACR Nuclear Medicine and PET Accreditation Program, to include the application process, clinical images submission and quality control requirements.
35(2008); http://dx.doi.org/10.1118/1.2962375View Description Hide Description
35(2008); http://dx.doi.org/10.1118/1.2962376View Description Hide Description
The PET Phantom accreditation data are acquired with the ACR PET phantom. The phantom is relatively easy to fill and set up for a PET study and can be used to measure tomographic uniformity, spatial resolution, and the detectability of “hot” lesions. The variety of resolution and “hot” components enables thereviewers to see relatively subtle differences in system performance.
The accreditation phantom images are submitted to a review panel of qualified medical physicists for scoring. The Nuclear Medicine Accreditation Committee has defined acceptable standards for uniformity, spatial resolution and lesion detection.
Uniformity and noise are evaluated qualitatively by inspection of reconstructed tomographic sections. Optimal density ranges should be comparable to those used for clinical images.Spatial resolution is judged by identifying thesmallest “cold” rods in the phantom and lesion detectability is determined from the “hot” cylinders. The same protocol is also used for the “cold” cylinders that demonstrate the effectiveness of the attenuation and scatter corrections.
1. Be aware of the ACR PET accreditation process and PETPhysicist Qualifications.
2. Understand the ACR PET Phantom and testing required for ACR accreditation.
3. Understand how phantom images are reviewed by the ACR.
4. Be able to activate the ACR Phantom.
5. Understand phantom image acquisition and processing.
6. Understand PET phantom imagecontrast, resolution, and uniformity.
- CR Mammography — What You Need to Know
35(2008); http://dx.doi.org/10.1118/1.2962410View Description Hide Description
The approval by the FDA of the Fuji FCRm in November 2006 allowed many facilities the opportunity to enter the era of Full‐Field digital imaging in mammography while utilizing their existing equipment previously using a film/screen imaging system. Although the mammography equipment producing the images spans the complete range of currently approved units from systems more than 10 years old to relatively new units, the image quality requirements for the Fuji FCRm system is independent of the equipment used to produce the images. The qualified medical physicist providing services to these facilities must be familiar with all aspects of the FCRm system to set up and oversee the Quality Control Requirements and to complete the required acceptance test procedures. This workshop will cover the required tests and evaluations of the FCRm system to be performed by the physicist covering the image producing equipment, the softcopy review workstations and the laser printer. Practical tips for performing these tests will be presented along with suggested worksheets.
1. Attendees will know the Annual Tests required to be performed by the medical physicist to meet MQSA and ACR accreditation requirements.
2. Attendees will be aware of methods to be used to perform the required tests of the Fuji FCRm system to meet accreditation requirements.
3. Attendees will know the acceptable range of values required for each of the tests to be performed by the medical physicist to meet accreditation requirements and values to be used to establish the ongoing Quality Control program.
- Routine Testing of CR and DR Radiographic Systems
35(2008); http://dx.doi.org/10.1118/1.2962558View Description Hide Description
Development of standards for performance verification of digital radiographic systems has been outpaced by commercialization of the technology. Practitioners, operators, vendors, and medical physicists are uncertain as to how to configure, calibrate, and verify systems for the best diagnostic quality images at the lowest practical radiation exposure to the patient. Several manufacturers have fielded commercial systems for performance verification, but long term data indicating trends and action limits is rare. Sources of definitive information on practical clinical methods are also scarce in the scientific literature. This has led to the current situation where clinical imaging operations are routinely conducted using systems that are not optimized.
This workshop will discuss four important aspects of traditional medical physics practice that are modified when dealing with DR systems. These processes are of primary importance to medical physicists, because they affect both the quality of DR images and the ionizing radiation dose to patients. First, we consider how to perform an inspection on a radiographic unit using CR or DR. Second, we discuss how to set up the AEC for CR or DR exams. Third, we address how to verify the exposure indicator for CR and DR. Last, we discuss available phantoms and their characteristics and limitations when used with DR.
1. Understand how some conventional tests should be modified for a digital radiographic system that is integrated into an electronic image management system.
2. Identify key references and standards that can be useful in testing of DR.
3. Appreciate opportunities for improvement of testing of DR systems.
- Diagnostic Radiology Resident Education
35(2008); http://dx.doi.org/10.1118/1.2962636View Description Hide Description
This session provides a forum for discussion of the progress made in improving diagnostic radiology resident education and some of the opportunities in education becoming available due to new technologies available to the teacher and student.
The first speaker will discuss the status of the curriculum for medical physicseducation of residents. At RSNA in November 2007, the AAPM medical physics resident curriculum committee met to review the first draft of new learning objectives which are being written for each section of the curriculum. The learning objectives are defined in three areas: 1) Fundamental Knowledge; 2) Clinical Application; and 3) Clinical Problem Solving. Radiologists and physicists are working together to develop these with a strong emphasis on clinical relevance.
The second speaker will describe the efforts of a task force formed under the leadership of William Hendee, Ph.D. (AAPM) and George Bissett, M.D. (RSNA) to develop free web‐based educational modules for radiologic science (medical physics)education of residents. Two modules have been developed: one on CTdose and a second on interventional radiology dose and safety. RSNA has agreed to host these modules on their web site and will make them available free of charge to any AAPM (physicists) or RSNA members (radiologists and residents). Most important, both AAPM and RSNA have contributed substantial funds to encourage the development of these education modules. Authors will receive $3,000–$4,000 for the development of each module. Approximately 50 modules are planned. A Request for Proposals has been distributed requesting authors to contribute modules. Each physics module must be authored by a physicist and a radiologist and must follow specific guidelines regarding content, objectives, required post test and the use of clinical materials in the educational process. These modules will be useful for both residents in training and radiologists in clinical practice through their maintenance of certification process.
The third speaker will provide a keynote lecture on “Evolving Models of Medical Image Physics and Technology Education.” See his abstract description for further details.
35(2008); http://dx.doi.org/10.1118/1.2962637View Description Hide Description
The effective and safe utilization of the various medical imaging modalities requires professionals (radiologists,medical physicists, and technologists) with a comprehensive and up‐to‐date knowledge of the physical principles of the imaging procedures along with an understanding of the technology and its operating characteristics.
Educational activities to meet these needs are characterized and often limited by issues of effectiveness and efficiency. The effectiveness of a activity determines outcomes and whether or not the learner will be capable of performing specific functions such as image quality evaluation, procedure optimization, applying appropriate risk management procedures, to name just a few. The efficiency of a learning activity is determined by a combination of factors including financial cost, human time and effort, and institutional and facility resources.
The work of two major pioneers in the educational process, Robert Gagne and Edgar Dale, provide us with an invaluable background and understanding of the learning process, and especially the compromises between effectiveness and efficiency.
There are several dynamics driving changes in the medical imagingeducational process and resulting in new and evolving models. These include rapid changes in imaging technology and methods, diffusion of the new technologies throughout the global healthcare system, and the need for enriched learning environments and adequately prepared learning facilitators (instructors) at the local level.
Continuing advances in digital technology are providing the infrastructure for increasing both the efficiency and effectiveness of medical imagingphysics and technology education. This is being achieved by the utilization of technology to enhance (and not replace) human performance of both the learners and learning facilitators and to create enriched learning environments.
The models of the educational systems for the future contain a combination of inter‐related functions that together address the changing needs and provide solutions. There are three major phases in the development and delivery of medical imagingphysics education. They are educational resource development, resource distribution and sharing, and resource utilization. Each of these is enhanced by the availability of state‐of‐the‐art digital technology but is also dependent on highly qualified and dedicated medical physicists along with institutional and organizational values and objectives.
The development of effective learning and teaching resources requires medical physicists with applied clinical experience who also have the capability to transfer the experience into effective learning resources—that is, resources that can be used to enrich learning environments and provide experiences that are as close as possible to actual medical imaging procedures and related activities. The most significant elements in effective learning resources are images and other visual graphics depicting the various imaging technologies and procedures. Clinical images demonstrating the imaging conditions and effects of imaging parameters are essential. A variety of image processing methods are used to create other highly effective teaching images and visuals. It is expected that simulators will become more prevalent in the future that will give learners the opportunity to observe images under interactive conditions.
The internet is revolutionizing medical imagingphysics education by providing a system for distributing and sharing resources, access to a variety of educational programs, teleteaching, and connectivity to a world‐wide knowledge base. This great value is demonstrated by one example. An educational resource on some major development or issue can be created and then made available around the world within a matter of hours. The technology is relatively mature but there are many organizational and economic issues that must be addressed before the full capability and value of this contribution to education is fully realized.
The effective utilization of the growing array of web‐accessible resources to produce the desired outcomes (effective and safe use of medical imaging technology) at the local level is enhanced by experienced medical physicists and institutional commitment and support for the higher levels of learning.
Web‐based resources for physics and technology education, especially for radiology residents, fellows, and then practicing radiologists, should support a continuum of integrated learning activities and experiences that typically begin with formal classes. Supervised and mentored clinical activities are major applied physicslearning activities where the online resources can be used under the guidance of the radiology and radiological physics faculty to demonstrate many concepts and applications. Preparation for board examinations provides a stimulus for reviewing previously studied resources. Web‐based resources are especially valuable for continuing education/ lifelong learning activities and references for questions and issues that are encountered during a clinical career.
Several components and functions of the evolving educational system (classroom lectures, online modules, etc) are analyzed with respect to their effectiveness and efficiency for meeting the educational needs of the medical imaging profession.
This course will be of value to all who are involved in medical physics and medical imagingeducation and who have an interest in the evolution of the process that is occurring now and leading into the future.
1. Identify and establish appropriate learning outcomes for specific medical professionals.
2. Establish the types and levels of learning that will be required to produce the desired outcomes.
3. Know the characteristics of learning activities that determine effectiveness.
4. Analyze current or proposed learning activities with respect to efficiency.
5. Understand the characteristics, especially effectiveness and efficiency, of the different models for educational activities.
6. Identify the elements that contribute to an enriched learning environment.
7. Plan and conduct educational activities that maximize effectiveness and efficiency.
8. Develop learning facilitators (faculty) who can optimize their performance as medical physicist educators.
9. Use technology as an appropriate tool in the educational process.
10. Contribute experience and resources to the extended medical physics community through shared resources.
- The Challenges of CT Accreditation
35(2008); http://dx.doi.org/10.1118/1.2962728View Description Hide Description
Purpose: To present various manufactured CTscanners with respect to the CT accreditation process and how the challenges of the process can be overcome.
The purpose of the accreditation program is to set quality standards for practices and help them continuously improve upon the quality of care they give to their patients. Designed to be educational in nature, the ACR Accreditation Programs evaluate qualifications of personnel, equipment performance, effectiveness of quality control measures, and quality of clinical images. It is believed that these are primary factors that affect the quality of clinical images and ultimately the quality of patient care.
The ACR CT accreditation program was established in 2002. The development of CT technology since then has been rapid and diverse. This has posed many challenges to the medical physicist in obtaining accreditation as well as in the implementation of an ongoing QC program for the vast array of scanners. A brief overview of the various type scanners with an emphasis on equipment specific challenges will be presented to facilitate this process.
- HAZMAT Training Course Part I
- HAZMAT Training Course Part II
- Introducing Brachytherapy Into the Clinic
35(2008); http://dx.doi.org/10.1118/1.2962881View Description Hide Description
The development of Brachytherapy began with the purification of radium by Pierre and Marie Curie. Due to early clinical practice using Radium, several systems were developed to standardize the practice as well as the emergence of different techniques: intracavitary, interstitial, intraluminal and surface molds. Brachytherapy implants can also be temporary or permanent. A list of resources will be provided covering the basics and history of Brachytherapy but the focus of this aspect of the workshop will be on the most common current utilization: permanent prostate seed implants. Topics to be covered include: isotope characteristics and selection, pre‐planning and ordering, receipt and activity verification, implantation, and post‐planning.
1. Review the isotopes in vogue, prescription ranges, and common clinical characteristics.
2. Review isotopemanufacturing and calibration issues.
3. Review of current implant techniques (Mick ® versus stranded).
4. Review radiation safety and release criteria.
5. Review post plans and lessons learned the hard way.
35(2008); http://dx.doi.org/10.1118/1.2962882View Description Hide Description
Brachytherapy has been utilized as a modality for treating cancer since shortly after the discovery of radium by Madame Curie in the early 1900's. Although radium was the workhorse for brachytherapy treatments in the first half of the 21st century, alternative sources began to emerge in the 1950's as mechanisms to produce radioactive isotopes were discovered. Cesium‐137, and a number of other low dose rate (LDR) sources were soon utilized clinically. However, it was not until the 1980's that high dose rate (HDR) brachytherapy emerged as a possible alterative to LDR treatments. Although HDR had the advantage of delivering dose in a shorter time frame, there were several concerns regarding this transition, such as the radiological response of HDR versus LDR treatments, and staff safety. Prior to the era of HDR units, most sources were loaded manually resulting in occupational dose to staff participating in LDR procedures. However, before HDR programs could be utilized clinically, alternatives for manual loading were necessary as the resulting exposure to staff would be prohibitively high. In response, remote afterloading HDR units emerged, allowing sources to be delivered to patients remotely. However, along with this advancement in technology came increasing regulatory and quality assurance requirements.
Although there are a number of similarities between LDR and HDR treatments, there are substantial differences in the clinical implementations of these treatment programs. During this presentation, we will discuss relevant federal regulatory requirements, NRC licensing, AAPM recommendations and task group reports, available HDR equipment, and logistical planning in order to develop a successful HDR program.
1. Discuss the necessary steps to prepare for the clinical implementation of a HDR brachytherapy program.
a. NRC licensing
b. Equipment purchase
c. Room design and shielding
d. Acceptance testing and commissioning
e. Quality assurance
2. Discuss logistics for HDR workflow.
- Introducing Brachytheraphy Into the Clinic
35(2008); http://dx.doi.org/10.1118/1.2962884View Description Hide Description
Electronic Brachytherapy (EBT) is internal radiation therapy that involves placing a miniature x‐ray source inside the patient close to or in the tumor. Recently, one EBT system (Axxent, Xoft Inc., Fremont, CA) has been released for clinical use. Because of its novelty, EBT has been relatively unstudied thus far in the clinical setting and is consequently unfamiliar to many medical physicists. The EBT modality offers several advantages over the Ir‐192 standard of care HDR brachytherapy source. Because of the relatively low energy of the EBT device (50 kV), treatments can be delivered in an unshielded room in contrast to the shielding required for HDR brachytherapy. The low external exposure rate also allows staff to remain near the treatment couch during dose delivery, offering the opportunity to provide comfort and encouragement in close proximity to the patient.
As yet, recommendations for the commissioning of an EBT system have not been officially drafted. However, commissioning an EBT system should include tests of well‐chamber constancy, beam stability, source positional accuracy, output stability, timer linearity, dummy marker/source position coincidence, controller functionality and safety interlocks and treatment planning data verification following AAPM TG43 recommendations.
Early EBT systems focused on treatment of the breast, using an intracavitary balloon catheter surgically implanted in a lumpectomy excision cavity. In comparison to Ir‐192, the EBT treatment results in a higher dose on the applicator surface, an equivalent distribution over the target region and a lower dose to normal structures around the implant area. Recent FDA clearances will allow the extension of EBT to additional sites, including endometrial applications.
This lecture will provide an overview of EBT, a commissioning procedure, and examples of its clinical use.
1. Gain basic knowledge of EBT as a potential HDR‐alternative treatment modality.
2. Understand a proposed commissioning protocol for an EBT system.
3. Learn about the current clinical uses for EBT.
Conflict of Interest: Partial financial support was provided by Xoft, Inc.
- Introducing Brachytherapy Into the Clinic
TH‐C‐352‐04: Acceptance Testing, Commissioning, Data Entry, and QA for Brachytherapy Treatment Planning Systems35(2008); http://dx.doi.org/10.1118/1.2962885View Description Hide Description
Clinical medical physicists are compelled to concern with accuracy of brachytherapytreatment planning systems as the basis for treatment delivery. The role of the medical physicist in brachytherapy is key — close interactions with physicians are needed, and often a radiation therapist may not be present. In comparison to external beam, dose gradients are steeper, record‐and‐verify is not typically used, and treatment fraction dose is usually higher. Thus, the importance of our input. The role of brachytherapy for cancertreatment has expanded in recent years. Many of these new modalities push the limits of the conventional brachytherapytreatment planningdose calculation algorithm. A solid understanding of these systems and their clinical role is crucial towards ensuring success. This tenet holds true for both the newer modalities and the more established brachytherapy procedures.
This continuing education lecture will provide a quasi‐chronological overview of the resources and actions required of a clinical medical physicist
1. Acceptance Testing and Commissioning recommendations.
2. Data Entry of brachytherapydosimetry parameters based on AAPM‐, manufacturer‐, and user‐provided data.
3. Quality Assurance, including startup and on‐going efforts, towards ensuring a safe and accurate environment.