CAR PRACTICE GUIDELINES AND TECHNICAL STANDARDS FOR BREAST IMAGING AND INTERVENTION APPROVED ON SEPTEMBER 29, 2012 CHAIR, SHIELA APPAVOO, MD; ANN ALDIS, MD; PETRINA CAUSER, MD; PAVEL CRYSTAL, MD; BENOÎT MESUROLLE, MD; YOLANDA MUNDT, MRT; NEETY PANU, MD; JEAN SEELY, MD; NANCY WADDEN, MD MODIFIED ON SEPTEMBER 17, 2016: CHAIR, SHIELA APPAVOO, MD; ANN ALDIS, MD; PETRINA CAUSER, MD; PAVEL CRYSTAL, MD; ANAT KORNECKI, MD; YOLANDA MUNDT, MRT; JEAN SEELY, MD; NANCY WADDEN, MD The practice guidelines of the Canadian Association of Radiologists (CAR) are not rules, but are guidelines that attempt to define principles of practice that should generally produce radiological care. The radiologist and medical physicist may modify an existing practice guideline as determined by the individual patient and available resources. Adherence to CAR practice guidelines will not assure a successful outcome in every situation. The practice guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The practice guidelines are not intended to establish a legal standard of care or conduct, and deviation from a practice guideline does not, in and of itself, indicate or imply that such medical practice is below an acceptable level of care. The ultimate judgment regarding the propriety of any specific procedure or course of conduct must be made by the physician and medical physicist in light of all circumstances presented by the individual situation. Approved on September 29, 2012 Chair, Shiela Appavoo, MD; Ann Aldis, MD; Petrina Causer, MD; Pavel Crystal, MD; Benoît Mesurolle, MD; Yolanda Mundt, MRT; Neety Panu, MD; Jean Seely, MD; Nancy Wadden, MD ModifiedChair, Shiela On Appavoo,September MD 17,; Ann 2016: Aldis, MD; Petrina Causer, MD; Pavel Crystal, MD; Anat Kornecki, MD; Yolanda Mundt, MRT; Jean Seely, MD; Nancy Wadden, MD ii TABLE OF CONTENTS Preamble ........................................................................................................................................................... 3 Section A: Breast Imaging ............................................................................................................................ 4 1. Mammography ....................................................................................................................................... 4 1.1. Screening Mammography ................................................................................................................................. 4 ............................................................................................................................................................. 4 Indications .......................................................................................................................................................... 4 SelfDefinition referral ......................................................................................................................................................... 5 ............................................................................... 5 Equipment .......................................................................................................................................................... Qualifications and Responsibilities ............................................................................................................ of Personnel The Screening Mammography Report .................................................................................................... 68 SpecificationsQuality Control of ....................................................................................................................... the Examination ........................... 79 Quality Assurance ............................................................................................................................................ 9 1.2. Diagnostic Mammography and Problem Solving Breast Evaluation ...........................................10 ...........................................................................................................................................................10 Goal ......................................................................................................................................................................10 IndicationsDefinition ........................................................................................................................................................10 .............................................................................10 Equipment ........................................................................................................................................................10 Qualifications and Responsibilities .......................................................................................................... of Personnel 11 The Diagnostic Report .................................................................................................................................11 DoubleSpecifications Reading of and the ComputerExamination Assisted Detection (CAD)...........................................................11 1.3 Tomosynthesis.......................................................................................................................................................11 2. Breast Ultrasound ...............................................................................................................................13 Indications ........................................................................................................................................................13 .............................................................................13 ..........................................................................................................14 DocumentationQualifications and ........................................................................................................................ Responsibilities of Personnel .......................14 Specifications of the Examination ...........................................................................................................................15 Quality Improvement Programs ..............................................................................................................15 2.1. ElastographyEquipment Specifications .........................................................................................................................................................15 2.2. Automated Whole Breast Ultrasound (AWBUS) ....................................................................................16 3. Breast MRI .............................................................................................................................................16 General Principles ......................................................................................................................................... Indications/Contraindications ................................................................................................................. .............................................................................16 Documentation ...............................................................................................................................................1816 Qualifications and Responsibilities ........................................................................................................................... of Personnel 1718 Quality Control Program .............................................................................................................................19 EquipmentProtocols ........................................................................................................................ Specifications ....................................20 High-spatial Resolution Sequences ........................................................................................................20 Basic Requirements for Breast MRI .......................................................................................................20 Quality Assurance ..........................................................................................................................................21 3.1. Diffusion Weighted Imaging ...........................................................................................................................21 3.2. Spectroscopy ..........................................................................................................................................................22 4. Alternative Imaging Methods .........................................................................................................22 4.1. Thermography ......................................................................................................................................................22 1 5. Emerging Technologies .....................................................................................................................22 Section B: Breast Intervention .................................................................................................................23 1. General Principles ..............................................................................................................................23 2. Biopsies