PGMI Digital Image

Reference Set
Version 1, February 2011

For comment and feedback please contact

Steph Tamblyn stamblyn@breastscreen.org.au

or
Liz Stewart estewart@breastscreen.org.au
18th February 2011

Enquiries to: Ms Stephanie Tamblyn

Telephone: 0412 551 282
Email: steph@miahealth.net
stamblyn@breastscreen.org.au

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 recognized that it is not definitive and is open to some interpretation. It should be

used as a guide and part of a wider selection of assessment. It has a valuable role in
assisting determination of areas for improvement or requiring attention.

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

L pec not down to level of

nipple but R pec just makes it

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

This criteria has been revised for Digital environment to widen

in profile to include nipple being transected by skin edge as
part of acceptable G grading
Nipple profile clearly seen in these CCs
Nipple profile
examples 10

Nipple profile transected by skin edge and acceptable

as part of a G grading if all other criteria are met
 11
Nipple profile
examples

Nipple profile not transected by skin

edge and deemed off profile
therefore not sufficient for G grading
One Third rule 12
Where the breast is well positioned
and meets the PNL criteria, a line
perpendicular to the PNL and
parallel to the long axis of the
image can be drawn from the
chest wall. If the skin edge
disappears at the line or within its
margin then a further lateral aspect
image may not be required. If the
skin edge is beyond the margin a
further view needs to be performed

This is intended as a guide for staff

but will be dependent on
radiologist preference at Service
 13
G
Nipples on CCs are
transected
Clipping of lateral aspect
minimal and may be
acceptable by some
services (see slide 12 -
rule)
MLOs asymmetry of height
if matched up similar width
losing small amount RMLO
upper is acceptable for G
 14
M
No IMA seen on either MLO
Clipping of lateral aspect
perceived as skin only
however, may require another
view depending on radiologist
preference at Service (see slide
12 - rule)
If relying on skin contour to
define upper boundary of MLO
then this image is missing
tissue of the upper breast
aspect
CCs have nipple transected by
skin edge
 15

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 -if CC views well positioned with nipples in profile

I -if nipples not in profile on CCs and/or tissue missing
 20

M
Gross skin folds in axilla

Twists at both IMAs, not into

breast but IMAs not clearly
seen
 Summary
MIAP2 propose BSA adopt revised PGMI criteria for digital
images
Digital Image Reference set to be compiled no later than
March 2011
This set has had input from key BreastScreen radiographers in
each state and welcomes further input from appropriate
jurisdictional people within BSA
Review of criteria and reference tool in 12 months
Recognize there will be some service variances but would be
good to try and reach some consensus on as much as
possible
PGMI is one component of image monitoring and should be
seen as a useful tool to assist in maintaining standards and in
supporting staff who require help with techniques

Liz Stewart estewart@breastscreen.org.au

or
Steph Tamblyn stamblyn@breastscreen.org.au