Position paper: recommendations for a digital mammography quality assurance program V4.0.

In 2001 the ACPSEM published a position paper on quality assurance in screen film mammography which was subsequently adopted as a basis for the quality assurance programs of both the Royal Australian and New Zealand College of Radiologists (RANZCR) and of BreastScreen Australia. Since then the clinical implementation of digital mammography has been realised and it has become evident that existing screen-film protocols were not appropriate to assure the required image quality needed for reliable diagnosis or to address the new dose implications resulting from digital technology. In addition, the advantages and responsibilities inherent in teleradiology are most critical in mammography and also need to be addressed. The current document is the result of a review of current overseas practice and local experience in these areas. At this time the technology of digital imaging is undergoing significant development and there is still a lack of full international consensus about some of the detailed quality control (QC) tests that should be included in quality assurance (QA) programs. This document describes the current status in digital mammography QA and recommends test procedures that may be suitable in the Australasian environment. For completeness, this document also includes a review of the QA programs required for the various types of digital biopsy units used in mammography. In the future, international harmonisation of digital quality assurance in mammography and changes in the technology may require a review of this document. Version 2.0 represented the first of these updates and key changes related to image quality evaluation, ghost image evaluation and interpretation of signal to noise ratio measurements. In Version 3.0 some significant changes, made in light of further experience gained in testing digital mammography equipment were introduced. In Version 4.0, further changes have been made, most notably digital breast tomosynthesis (DBT) testing and QC have been addressed. Some additional testing for conventional projection imaging has been added in order that sites may have the capability to undertake dose surveys to confirm compliance with diagnostic reference levels (DRLs) that may be established at the National or State level. A key recommendation is that dosimetry calculations are now to be undertaken using the methodology of Dance et al. Some minor changes to existing facility QC tests have been made to ensure the suggested procedures align with those most recently adopted by the Royal Australian and New Zealand College of Radiologists and BreastScreen Australia. Future updates of this document may be provided as deemed necessary in electronic format on the ACPSEM's website ( https://www.acpsem.org.au/whatacpsemdoes/standards-position-papers and see also http://www.ranzcr.edu.au/quality-a-safety/radiology/practice-quality-activities/mqap ).

Interim recommendations for a digital mammography quality assurance program.

In 2001 the ACPSEM published a position paper on quality assurance in screen film mammography which was subsequently adopted as a basis for the quality assurance programs of both the Royal Australian and New Zealand College of Radiologists (RANZCR) and of BreastScreen Australia. Since then the clinical implementation of digital mammography has been realised and it has become evident that existing screen-film protocols were not appropriate to assure the required image quality needed for reliable diagnosis or to address the new dose implications resulting from digital technology. In addition, the advantages and responsibilities inherent in teleradiology are most critical in mammography and also need to be addressed. The current document is the result of a review of current overseas practice and local experience in these areas. At this time the technology of digital imaging is undergoing significant development and there is still a lack of full international consensus about some of the detailed Quality Control tests that should be included in quality assurance (QA) programs. This document describes the current status in digital mammography QA and recommends test procedures that may be suitable in the Australasian environment. For completeness, this document also includes a review of the QA programs required for the various types of digital biopsy units used in mammography. In the future, international harmonisation of digital quality assurance in mammography and changes in the technology may require a review of this document. Accordingly, updates of this document will be provided as deemed necessary in electronic format on the ACPSEM's website (see http://www.acpsem.org.au/au/subgroup/radiology/RadiologySG_index.html).

Automatic technique parameter selection on a digital mammography system: an evaluation of SNR and CNR as a function of AGD on a GE senographe DS.

There are obvious differences in the automatic selection of kVp, anode, and filter between a digital mammography system and the equivalent film/screen system for the same thickness of PMMA absorber. To investigate the reason for these changes, a large number of images were acquired using 2, 4, 6, and 8 cm thick PMMA absorbing slabs, and various combinations of kVp, mAs, anode, and filter. The SNR and CNR were calculated using two different contrast test objects and plotted as a function of AGD. The results can be summarized as follows: 1) For any given AGD with 4, 6, and 8 cm thick PMMA absorbers, SNR(Rh/Rh) > SNR(Mo/Rh) > SNR(Mo/Mo), 2) For any given AGD: At 4 cm thickness, CNR(Mo/Mo) > CNR(Mo/Rh) > CNR(Rh/Rh), At 6 cm thickness, CNR(Rh/Rh) approximately CNR(Mo/Rh) > CNR(Mo/Mo), At 8 cm thickness, CNR(Rh/Rh) > CNR(Mo/Rh), 3) For any given absorber thickness and target/filter combination, CNR is approximately proportional to SNR, 4) For any given absorber thickness and target/filter combination, SNR (and hence CNR) is approximately proportional to (AGD)0.3 rather than the expected (AGD)(0.5), 5) CNR measured using 0.1 mm thick aluminium foil as the contrast object is more dependent on choice of kVp than using a 1 mm deep hole in a PMMA slab.

Measurement of CT scanner dose profiles in a filmless department.

The measurement of the FWHM of the slice thickness radiation dose profile of a CT scanner using a prototype low sensitivity CR imaging plate has been investigated, as an alternative to the traditional method using envelope-packed industrial film. Using a standard Agfa clinical CR system to acquire the image, the FWHM of the dose profile can be accurately measured using readily available Public Domain software. An Agfa 18 x 24 cm CR cassette gives a pixel pitch of 113.5 microm, but with interpolation, the measurement accuracy can be less than 1 pixel. For a nominal 10 mm collimation, 15 successive measurements of the FWHM using CR gave an average width of 10.00 mm with a standard deviation of 0.02 mm. This may be compared with 4 successive measurements using film and a dual exposure technique to define the optical density at half peak height, yielding an average width of 9.98 mm with a SD of 0.03 mm. This prototype NDT plate is not a commercial product, but a radiotherapy plate with a similar sensitivity is available commercially and should give similar results.

Characterization of the intracellular signalling pathways that underlie growth-factor-stimulated glucose transport in Xenopus oocytes: evidence for ras- and rho-dependent pathways of phosphatidylinositol 3-kinase activation.

The stimulation of glucose transport is one of the early cellular responses to growth factors and is essential for cell proliferation, yet the molecular processes that underlie this response are poorly defined. The aim of this study was to characterize the role of the low-molecular-mass G-proteins, Ras and Rho, and their downstream targets, Raf protein kinase and phosphatidylinositol 3-kinase, in the regulation of glucose transport in Xenopus oocytes by two distinct growth-factor receptors: the insulin-like growth factor I (IGF-I) tyrosine kinase receptor and the heterotrimeric G-protein-coupled lysophosphatidic acid (LPA) receptor. Microinjection of a neutralizing anti-Ras antibody partially blocked IGF-I-stimulated deoxyglucose uptake but was without effect on LPA-stimulated deoxyglucose uptake. In contrast, microinjection of the C3 coenzyme of botulinum toxin, which selectively ADP-ribosylates and inactivates Rho, inhibited LPA-stimulated, but not IGF-I-stimulated, deoxyglucose uptake. Similarly, LPA- but not IGF-I-stimulated deoxyglucose uptake was attenuated in oocytes expressing a dominant negative rho construct. Cells expressing a dominant negative mutant of Raf protein kinase exhibited markedly reduced sensitivity to both LPA and IGF-I, consistent with a role for endogenous Raf in glucose uptake by both growth factors. Furthermore, expression of a constitutively activated form of raf-1 resulted in a growth-factor-independent increase in deoxyglucose uptake. Measurements of phosphatidylinositol 3-kinase activity in microinjected cells support the hypothesis that the IGF-I receptor stimulates glucose transport by a Ras-dependent activation of phosphatidylinositol 3-kinase, whereas the G-protein-coupled LPA receptor controls this response by a pathway that involves Rho-dependent activation of a distinct phosphatidylinositol 3-kinase. Thus we provide evidence for clear differences in the signalling pathways that control glucose transport by G-protein-coupled and tyrosine kinase growth-factor receptors. Furthermore this is the first demonstration that active Rho is involved in the signalling pathways that regulate glucose uptake in response to some growth factors.

Three-dimensional CT angiography in the detection and characterization of intracranial berry aneurysms.

PURPOSE: To assess the accuracy of three-dimensional CT angiography (CTA) in the detection and characterization of intracranial aneurysms and to help determine its role as a screening test for aneurysms in the asymptomatic population and as an adjunct to angiography in subarachnoid hemorrhages and in the follow-up of untreated aneurysms. METHODS: In a blinded, prospective study, the 3-D CTA studies in 80 patients with symptomatic aneurysms were analyzed for the presence and morphology of aneurysms. Angiography or surgery acted as the control. RESULTS: Ninety-four aneurysms were found in 63 patients. Negative findings at angiography were noted in 17. Sensitivity and specificity of 3-D CTA for all aneurysms, all patients, and aneurysms 5 mm or smaller were 90.4% and 50%, 98.4% and 82.4%, and 78.8% and 51.9%, respectively. CONCLUSION: Three-dimensional CTA may have a role in noninvasive screening for asymptomatic aneurysms in the general population, but caution is advocated when data obtained from symptomatic patients are extrapolated to the asymptomatic population who harbor smaller aneurysms. Also, 3-D CTA may be useful as an adjunct to angiography in the characterization of berry aneurysms and in the follow-up of untreated aneurysms.

Evidence for a role of phospholipase A2 in the mechanism of LHRH priming in rat anterior pituitary tissue.

The phospholipase A2 (PLA2) inhibitors, quinacrine, p-bromophenacyl bromide, ONO-RS-082, aristolochic acid and chloracysine blocked the priming effect of LHRH, but not acute LHRH-induced gonadotrophin release measured in anterior pituitary pieces in pro-oestrous rats in vitro. These results suggest that the intracellular mechanisms underlying LHRH priming are distinct from those which mediate LH release in the present circumstances in that they involve PLA2. Furthermore, neither LHRH-induced LH release from preprimed tissue nor Ca(2+)-induced LH release were attenuated by quinacrine, indicating that this inhibitor does not interfere with the general Ca(2+)-dependent secretory apparatus of the gonadotroph and that the critical period for its action is in the induction of priming. LHRH induced the release of [3H]arachidonic acid ([3H]AA) from [3H]AA-prelabelled anterior pituitary tissue from pro-oestrous rats; a response which was sensitive to inhibitors of PLA2, of protein kinase C (PKC) and of protein synthesis. Activation of PKC also resulted in [3H]AA release which was inhibited with exactly the same pharmacological profile as the response to LHRH. Both gonadotrophin secretion and [3H]AA release responses to LHRH and to phorbol ester varied in parallel during the oestrous cycle and in ovariectomized/oestradiol-17 beta-replaced animals, as did their sensitivity to quinacrine and the protein synthesis inhibitor cycloheximide. These results indicate that LHRH priming is dependent on a hormonally regulated cascade involving a distinct form of PKC acting through a protein synthesis-dependent step to release AA by means of PLA2 activity. The priming effect was mimicked (at least in part) by conditioning preincubation with AA, confirming the functional relevance of this signalling cascade. Results using standard inhibitors of lipoxygenase/epoxygenase pathways were equivocal as to whether these pathways were critically involved, whilst cyclo-oxygenase inhibitors were completely without effect. The steps downstream from AA (and its possible metabolites) by which stimulus-secretion coupling is up-regulated in priming remain to be clarified.

Activation of serum response element-regulated genes by lysophosphatidic acid.

Lysophosphatidic acid (LPA) is an important constituent of serum and shares its mitogenic activity. Serum induction of several genes is regulated, at least in part, by sequences related to the c-fos serum response element (SRE). A Rat-2 fibroblast cell line containing the beta-galactosidase reporter gene under SRE control was treated with LPA. Lysophosphatidic acid induced a time- and dose-dependent increase in beta-galactosidase activity. After 5 hours of treatment with 1-oleoyl-LPA a 3-fold increase in beta-galactosidase activity was observed. In contrast, endogenous alkaline phosphatase activity did not change in parallel with the beta-galactosidase activity indicating that the induction was specific. Various LPAs with different acyl groups in the sn-1 position induced beta-galactosidase activity with a rank order potency of 1-oleoyl-LPA > 1-palmitoyl-LPA > or = 1-myristoyl-LPA > 1-stearoyl-LPA. Phosphatidic acid was approximately equal to 1-stearoyl-LPA. Neither the calcium ionophore (A23187) nor 12-O-tetradecanoylphorbol 13-acetate, induced beta-galactosidase activity. These data suggest that LPA may exert some of its effects by regulation of SRE controlled genes.

Activation of MAP kinase associated with the priming effect of LHRH.

A MAP kinase activity assay was developed to determine whether the LHRH receptor could activate this enzyme (particularly during LHRH priming). In anterior pituitary tissue from prooestrous rats LHRH caused concentration-dependent activation of MAP kinase after 5-10 min and continued for up to 60 min of incubation. The magnitude of this response correlated with that of LHRH priming on various days of the oestrous cycle but not with the magnitude of 1st hour (unprimed) LHRH-induced LH release. The response to LHRH was mimicked by a phorbol ester but not by ionomycin and was blocked with high potency by GF 109203X but not by H7 (in a similar manner to the PKC species that mediates LHRH priming). Neither the tyrosine kinase inhibitor lavendustin A nor the protein synthesis inhibitor cycloheximide blocked LHRH-induced MAP kinase activation. The possible functional significance of MAP kinase activation in gonadotrophs is considered with respect to LHRH priming.

Differential involvement of phospholipase A2 in phorbol ester-induced luteinizing hormone and growth hormone release from rat anterior pituitary tissue.

The protein kinase C (PKC) activator, phorbol 12,13-dibutyrate (PDBu) induced the release of both luteinizing hormone (LH) and growth hormone (GH) from proestrous rat anterior pituitary pieces in vitro. Phorbol 12,13-dibutyrate-induced LH, but not GH release was readily inhibited by the phospholipase A2 (PLA2) inhibitors, quinacrine, aristolochic acid, ONO-RS-082 and chloracysine. Furthermore, PDBu induced release of [3H]arachidonic acid ([3H]AA) from pre-labelled anterior pituitary tissue that was prevented in the presence of quinacrine, aristolochic acid and ONO-RS-082 but not the diglyceride lipase inhibitor RHC 80267. The effect of PDBu was completely inhibited by staurosporine and the selective PKC inhibitor Ro 31-8220 but only partially by low concentrations of H7; consistent with the involvement of both H7-sensitive and H7-resistant forms of PKC in the activation of PLA2 by PDBu. The protein synthesis inhibitor cycloheximide inhibited the release of both [3H]AA and LH that had been induced by PDBu, whereas LH release induced by the PLA2 activator mellitin was cycloheximide-insensitive. These results suggest that PKC activators may induce LH but not GH release from anterior pituitary tissue by a mechanism involving activation of a PLA2, brought about by a process which is reliant on protein synthesis.

The involvement of dihydropyridine-sensitive calcium channels in phorbol ester-induced luteinizing hormone and growth hormone release.

We examined the role of voltage-activated, L-type, Ca2+ channels in phorbol ester-induced luteinizing hormone (LH) and growth hormone (GH) release from rat anterior pituitary tissue. The L-type Ca2+ channel inhibitor, nimodipine (NMD), inhibited phorbol 12,13-dibutyrate (PDBu)-induced GH release but had no significant effect on LH release. The L-type Ca2+ channel activator BAY K 8644 had no effect on PDBu-induced GH release but potentiated PDBu-induced LH release. In contrast, 60 mM K(+)-induced LH and GH release were inhibited by NMD, whereas BAY K 8644 had no effect. When PDBu and either K+ or BAY K 8644 were used together, they acted synergistically to evoke levels of LH release greater than addition of release caused by each secretagogue alone. However, the release of GH was additive with PDBu and either K+, BAY K 8644. The protein kinase C (PKC) inhibitor staurosporine inhibited both PDBu-induced LH release and GH release. A structurally different PKC inhibitor, H7, significantly inhibited PDBu-induced LH release but had no effect on PDBu-induced GH release. Both staurosporine and H7 inhibited LH release induced by PDBu and BAY K 8644 together. In contrast, although staurosporine inhibited GH release induced by PDBu and BAY K 8644, H7 significantly potentiated this response. A difference in the action of these two inhibitors was also apparent on K(+)-induced hormone release where staurosporine partially blocked K(+)-induced LH and GH release but H7 had no effect on the release of either hormone. Data obtained in 45Ca2+ influx experiments further suggested that a staurosporine-sensitive, but H7-resistant, PKC-like kinase may tonically maintain L-channels in a voltage-sensitive state, as down-regulation of PKC in dispersed anterior pituitary cells by long term PDBu treatment caused a significant reduction in K(+)-induced 45Ca2+ influx. We conclude that phorbol ester-induced GH release, but not LH release, is a result of L-type Ca2+ channel activation which may occur by means of alterations in the channel itself to increase its responsiveness to a given depolarisation.

The differential effects of protein kinase C activators and inhibitors on rat anterior pituitary hormone release.

We investigated the possibility that various protein kinase C (PKC) activators and inhibitors may differentially affect luteinizing hormone (LH) and growth hormone (GH) release from rat anterior pituitary tissue, incubated in vitro. Activators of PKC induced LH release with the following order of potency: mezerein > phorbol 12,13-dibutyrate (PDBu). Mezerein and PDBu were equipotent on GH release. A range of PKC inhibitors (including compounds highly selective for PKC) potently and completely inhibited PKC activator-induced LH and GH release. Chelerythrine and 1-(5-isoquinolinesulfonyl)-2-methylpiperazine dihydrochloride (H7) were less potent inhibitors of PDBu-induced GH release than of LH release. A component of PDBu- and mezerein-induced LH release was inhibited by H7 with high potency, but a second H7-insensitive component was detected. Mezerein- and PDBu-induced GH release consisted of an H7-resistant component only. When the regulatory domain of PKCs from different sources was investigated by displacement of [3H]PDBu binding, the affinity for mezerein was 3-5-fold greater than that for PDBu at PKCs from cerebral cortex, lung and alpha and beta isoforms extensively purified from brain. Anterior pituitary PKCs were unusual in showing closely matched affinity for mezerein and PDBu, reminiscent of their equivalent potency on GH release. In order to investigate the potency of the catalytic domain inhibitor H7 on PKCs from different sources, enzyme activity assays were carried out on partially purified cytosolic PKCs from midbrain and anterior pituitary and on extensively purified PKC alpha and PKC beta. The Ca(2+)-independent component of PDBu-induced (phosphatidylserine-dependent) activity from anterior pituitary alone showed unusually low potency of inhibition by H7 but was potently inhibited by staurosporine and Ro 31-8220. In contrast, the Ca(2+)-dependent PKC activity in anterior pituitary was inhibited by H7, staurosporine and Ro-31-8220 with high potency as in all other preparations. These results are consistent with the presence and active role in secretion of pharmacologically distinct forms of PKC (or PKC-like kinases) in rat anterior pituitary cells.

Oestradiol-17 beta modulates the actions of pharmacologically distinct forms of protein kinase C in rat anterior pituitary cells.

Phorbol ester-induced release of LH and GH from rat anterior pituitary tissue in vitro is differentially inhibited by some, but not other, inhibitors of protein kinase C (PKC), suggesting that pharmacologically distinct species of PKC may have different functional roles in these cells. Since stimulus-induced anterior pituitary hormone release can be enhanced by oestradiol-17 beta (OE2) pretreatment, we investigated the effect of OE2 treatment of long-term (4 weeks) ovariectomized rats on the amount, activity and cellular actions of pharmacologically distinct PKC species in rat anterior pituitary tissue. Here we report that OE2 treatment enhanced phorbol 12,13-dibutyrate (PDBu)-induced LH but not GH release measured in vitro. This effect of OE2 on LH release may involve synthesis of additional PKCs that are not targeted by the synthetic diacylglycerol, 1,2-dioctanoyl-sn-glycerol (DOG). Measurements of anterior pituitary PKC activity and [3H]phorbol ester-binding studies suggested that the facilitatory action of OE2 on LH release may occur, at least in part, by altering the quantity and activity of PKC(s). Our results also demonstrate that the OE2-induced PKC(s) which facilitate LH release may be of the type that are not dependent upon raised intracellular Ca2+ for their activation and display distinct pharmacological properties (being readily activated by PDBu, but not by DOG, and are staurosporine-sensitive but H7-insensitive). This facilitatory action of OE2 on PKC-induced LH release does not appear to involve OE2-induced changes in the affinity of existing PKC(s) for PDBu, or changes in the amount of releasable LH in the pituitary prior to the stimulus.

The priming effect of luteinizing hormone-releasing hormone (LHRH) but not LHRH-induced gonadotropin release, can be prevented by certain protein kinase C inhibitors.

The priming effect of LHRH in vitro (which results in increased responsiveness of gonadotropes to both LHRH receptor-mediated and receptor-independent stimuli) is brought about by an unknown mechanism. The present results indicate that induction of the LHRH priming effect is inhibited in a concentration-dependent manner by the protein kinase C (PKC) inhibitors staurosporine, K252a, H7 and by the novel highly-selective PKC inhibitor, Ro 31-8220. In contrast, a range of other compounds that are relatively selective inhibitors of other kinases such as tyrosine kinases and Ca2+/calmodulin-dependent kinases were unable to prevent priming. The PKC inhibitors prevented priming without affecting initial LHRH-induced gonadotropin secretion. Thus, the priming-elicited increment in secretion was selectively removed, restoring hormone release to the level measured during an initial response to LHRH. Similar results were obtained on different days of the estrous cycle where the magnitude of the priming effect varies. Experiments on the time course of PKC inhibitor action revealed that the critical period was in the induction of the priming effect, not its expression. The PKC inhibitors had neither acute nor delayed effects on gonadotropin secretion induced by ionomycin. Staurosporine, K252a and Ro 31-8220 inhibited LHRH priming with identical potencies to their inhibition of phorbol ester-induced gonadotropin secretion. The reduced potency of H7 seen on LHRH priming compared to phorbol ester-induced gonadotropin release parallels results seen with this inhibitor on phorbol ester-induced secretion of growth hormone (Johnson and Mitchell (1989) Biochem. Soc. Trans. 17, 751-752) and on the pharmacological characteristics of PKCs partially purified from anterior pituitary tissue. In all aspects of this study, effects on luteinizing hormone (LH) and follicle-stimulating hormone (FSH) secretion appeared to be entirely similar.

Inhibition of depolarisation-induced calcium influx into GH3 cells by arachidonic acid: the involvement of protein kinase C.

The influx of 45Ca2+ induced in GH3 cells by exposure to 60 mM K+ medium was inhibited by arachidonic acid (AA) in a concentration-dependent manner. This action of AA was not prevented by inhibitors of its metabolism but was reversed by the inhibitors of protein kinase C (PKC), H7 and staurosporine but not their less active congeners HA 1004 and K252a, respectively. Presumed down-regulation of PKC by pretreatment with phorbol 12,13-dibutyrate (PDBu) also greatly diminished the effect of AA. Experiments to assess effects of AA on 45Ca2+ efflux and on cytosolic Ca2+ concentrations indicated that an additional PKC-independent action of AA involving the release of intracellularly stored calcium was present. Both direct activation of certain PKC isoform(s) by AA and the synergistic influence on PKC activity by its concomitant raising of intracellular Ca2+ concentrations, may be physiologically important in the regulation of depolarisation-induced Ca2+ entry.

Experimental evaluation of aortic homograft valves mounted on flexible support frames and comparison with glutaraldehyde-treated porcine valves.

The durability of the aortic homograft valve, when mounted in a rigid support frame, has been limited in some cases by aortic wall detachment from the frame in the commissure buttress area. To investigate the effects of frame flexibility, a stent was designed which was suitable for canine aortic valves of selected sizes. Of the two materials tested, acetal copolymer was found to be superior to polypropylene, as stents made from the latter material were permanently deformed as a result of polymer creep under the action of a cyclic load. Observations of a commercially available glutaraldehyde-treated heterograft mounted on a polypropylene frame indicated that stent flexibility was less important than had been suggested in earlier reports. It is considered that the glutaraldehyde preservation and the method of mounting this valve in the frame are major factors in prolonging the life of the implant.