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Reference Set
Version 1, February 2011
Dear Colleagues,
Please find on the following presentation the 1st version of the PGMI Digital Image
Reference set to be used as reference tool with the digital PGMI criteria.
As you will be aware there has been some debate since the introduction of digital
mammography on whether the current PGMI criteria should be re written or revamped. It
has caused concerns and angst for some radiographers that appear to have lowered
their gradings with the newer technology, largely due to the wider dynamic range that
allows clearer visualization of every crease or fold and the ability to see nipple profile.
The aim in screening is to produce consistent high quality breast imaging and
transparency and consistency of assessment. The PGMI criteria allows a review of
Images to take place against a set of criteria rather than individuals own ideas of what
constitutes a good image, with possible perceived bias or favouritism. In discussions the
general agreement is that the digital environment shows faults and highlights positioning
issues to a greater degree than analogue due to the greater tissue visibility. Those
radiographers who have poor technique or are sloppy or variable in their work standard
will be more noticeable. Those radiographers following the basic tenets of good
positioning technique and with knowledge of the modality being used will be able to
achieve the required NAS standard.
The AIR Medical Imaging Advisory Panel 2 have revised the standard set of criteria in
light of the digital technology and have submitted the proposed changes to the BSA
NQMC to consider for endorsement and implementation with review in 12 months once
digital imaging is further rolled out across the state services. The proposed changes are
minimal and it is believed are adequate when used with the PGMI Digital Image
Reference set. Opinions have been sought on the set provided and the 1st version of the
final set will be sent to the BSA program managers February 2011 meeting for
endorsement also. In general there is consensus that the PGMI grading should be
revised only. Whilst some have suggested a 3 grading criteria from Repeatable/
Inadequate through Moderate/Adequate to Good /High quality it has been thought wise to
keep the same criteria at least whilst there remains analogue imaging as well.
In 2005 Poulos et al looked at the PGMI and compared it with a suggested alternative 3
grade EAR criteria (E excellent A adequate R repeatable) Their conclusion was that
neither option was perfect and that the PGMI be retained in use until an alternative could
be found. Those involved in the above paper have continued research into the criteria
currently used and continue to search for clearer defined aims.
This PGMI Digital Image Reference set has had much input by BSA mammography
course providers. This set is a collation of these efforts but is only a start. It is anticipated
the image set will be further expanded and revised at the future planned review. We
would welcome any feedback from you at this time.
The following information is to accompany the test set:
The PGMI grading criteria should be used as a guide and tool for providing a form of
standardization of image reviewing. It allows a set of guidance rules for use by both
individual radiographers assessing their own work and reviewers assessing image sets
for radiographer training and as part of the NAS annual random image quality review.
It is important how the PGMI is introduced to staff and explanation is provided on the
NAS annual audit requirement for 50% grading requirement so it can be seen as a
positive process for the program and not an unrealistic or impossible goal.
It is important that Tutor and Designated Radiographers in BSA have some level of
consensus on their PGMI application on grading images. To that end a PGMI Digital
Image Reference set has been produced and annotated with comments on
acceptable agreed levels for crease and folds etc. so that it can be used as a
widespread reference resource.
It is envisaged it would be available across the services and online on the AIR
website as reference for all radiographers performing mammography
Yours sincerely,
Stephanie Tamblyn
Chairperson, Medical Imaging Advisory Panel 2 Breast & Ultrasound (MIAP2)
SOURCE: BreastScreen Australia National Accreditation Standards, July 2002,
Appendix M
RECOMMENDED STANDARD: A minimum of 50% of an audit of 50 randomly
selected image sets should be graded in the P or G categories
REPEAT RATE: <3% of consecutive images to be classified Inadequate.
The following slide shows (in red) the points
that have been modified for PGMI use in digital
SOURCE: BreastScreen Australia National Accreditation Standards, July 2002,
Appendix M
RECOMMENDED STANDARD: A minimum of 50% of an audit of 50 randomly
selected image sets should be graded in the P or G categories
REPEAT RATE: <3% of consecutive images to be classified Inadequate.
1
G
Minor asymmetry between width of pec
2
G
R CC has slight medial bias, not
sufficient to downgrade
3
G
Fingernail curve at IMA demonstrates
this area is visualized
4
M
R breast meets G criteria as nipple profile
transected on CC
Previous L breast surgery results in imaging
not meeting PGMI criteria for G
5
G
Slight asymmetry of pec length grades images as G not P
6
M
Breast well extended and breast tissue well elevated however
skin folds at IMA extend into breast tissue and angles not
clearly visualised
7
M
L IMA not clearly visualized, R
IMA borderline as there is a
slight dip at edge of image
Asymmetry of CC placement
is minor this may be
addressed by some
PACS/modality software
8
M
R MLO would have been G
as slight dip at edge of IMA
image seen
L MLO disappearing off
image so IMA not clearly
seen
R CC nipple transected
LCC nipple not transected
off profile
99
Nipple profile
examples
M
MLOs good extension but
IMAs not clearly demonstrated
due to twists
Borderline missing tissue at
upper aspect of MLO
16
M
MLOs Pecs not sufficient
length quite for G
Creases at IMA would be
acceptable for a G as
windowing through this
area allows for clear
visualization
CCs OK
17
M
Image meets G criteria for pec
width, length, nipple profile and
clear IMA but is downgraded to
M due to the gross skin fold
from axilla radiating into breast
tissue
18
G
MLO views OK -IMA just
seen on R
Nipple transected L MLO
CCs have slight medial
bias but graded G as PNL
of CCs within 1cm of PNL
of MLOs
19
Challenging client
Poor positioning and use of 2 views as should have had
IMAs clearly seen and nipples in profile on both outer MLO
views
M
Gross skin folds in axilla