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Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
www.elsevier.com/locate/jmir
Research Article
Local diagnostic reference levels (LDRLs) for full-eld digital mammography
(FFDM) and digital breast tomosynthesis (DBT) procedures in Morocco
Mohammed Talbi
a , ∗, M’hamed El Mansouri
b
, Oussama Nhila
b
, Zakaria Tahiri
c
, Khalida Eddaoui
d
and Mohammed Khalis
a
a
Faculty of Sciences, Moulay Ismail University, Meknès, Morocco
b
Faculty of Sciences,Ibn Tofail University, Kenitra, Morocco
c
Moroccan Agency for Nuclear and Radiological Safety and Security, Rabat, Morocco
d
Faculty of Medicine and pharmacy,Mohammed V University, Rabat, Morocco
Available online xxx
ABSTRACT
Introduction: The objective of this study was to establish local
diagnostic reference levels (LDRLs) for the full-eld digital mam-
mography (FFDM) and tomosynthesis (DBT) in Moroccan health
facilities.
Methods: Data from 146 women were collected from three facilities.
The proposed DRLs were dened as the 75th percentile of the mean
average glandular dose (AGD) distribution.
Results: The mean AGD recorded in this study for the three centers
was 1.47 mGy for all centers, and 1.42 mGy and 1.64 mGy for the
CC and MLO projections, respectively. The mean compressed breast
thickness (CBT) values recorded in this current study were 55 mm,
the LDRLs reported for all centers was 1.7 mGy, the CC projection
was 1.6 mGy, and the MLO projection was 1.8 mGy. In addition, the
LDRLs reported in the current study were compared with those from
previous studies for other countries, including the United Kingdom,
Japan, Ghana, and Sri Lanka.
Conclusion: This work provides an assessment of local DRLs for
mammography in Morocco and is suggested as a starting point that
will allow professionals to evaluate and optimize their practice. Fur-
thermore, the denition of national DRLs is a necessary process in
optimizing Moroccan medical exposures.
RÉSUMÉ
Introduction : L’objectif de cette étude était d’établir des niveaux
de référence diagnostiques locaux (NRDL) pour la mammographie
numérique plein champ (MNPC) et la tomosynthèse (DBT) dans les
établissements de santé marocains.
Méthodologie : Des données provenant de 146 femmes ont été re-
cueillies dans trois établissements. Les NRD proposés ont été dé-
nis comme le 75e percentile de la distribution de la dose glandulaire
moyenne (DGM).
Résultats : La DGM moyenne enregistrée dans cette étude pour les
trois centres était de 1,47 mGy pour tous les centres, et de 1,42 mGy
et 1,64 mGy pour les projections CC et MLO, respectivement. Les
valeurs moyennes de l’épaisseur comprimée du sein (ECS) enregistrées
dans cette étude étaient de 55 mm, les NRDL rapportés pour tous
Funding: This study did not receive any specic grant from funding agencies in the public, commercial, or not-for-prot sectors.
Competing interests: All authors declare no conict of interest.
Ethical approval: This study did not carry out activities that would require approval by institutionalethical board. This article does not contain any studies involving
human subjects.
CRediT authorship contribution statement:
Mohammed Ta lbi : Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing –review & editing.
M’hamed El Mansouri: Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing – review & editing.
Oussama Nhila: Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing – review & editing.
Zakaria Tahiri: Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing –review & editing.
Khalida Eddaoui: Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing –review & editing.
Mohammed Khalis: Conceptualization, Visualization, Funding acquisition, Formal analysis, Data curation, Writing – original draft, Writing –review & editing.
∗Corresponding author at: Faculty of Sciences, Moulay Ismail University, Meknès, Morocco.
E-mail address: [email protected] (M. Talbi).
1939-8654/$ - see front matter © 2022 Published by Elsevier Inc. on behalf of Canadian Association of Medical Radiation Technologists.
https://doi.org/10.1016/j.jmir.2022.03.008
Please cite this article as: M. Ta lbi, M.E. Mansouri, O. Nhila et al., Local diagnostic reference levels (LDRLs) for full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) procedures in Morocco, Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2022.03.008
ARTICLE IN PRESS
JID: JMIR [mNS; March 29, 2022;22:2 ]
les centres étaient de 1,7 mGy, la projection CC de 1,6 mGy et la
projection MLO de 1,8 mGy. En outre, les NRDL rapportés dans
l’étude actuelle ont été comparés à ceux d’études précédentes pour
d’autres pays, notamment le Royaume-Uni, le Japon, le Ghana et le
Sri Lanka.
Conclusion : Ce travail fournit une évaluation des NRD locaux pour
la mammographie au Maroc et est proposé comme un point de départ
qui permettra aux professionnels d’évaluer et d’optimiser leur pratique.
Par ailleurs, la dénition de NRD nationaux est un processus néces-
saire à l’optimisation de l’exposition médicale au Maroc.
Introduction
Breast cancer is a signicant public health issue; it is consid-
ered the leading cancer among women in Morocco and ac-
counted for 20% of cases recorded between 2008 and 2012.
[1] Mammography is the most eective weapon in the ght
against breast cancer because of its ability to detect the disease
early and reduce mortality. Therefore, it is imperative to ensure
a quality examination by controlling the relationship between
the dose to the breast and the quality of the image to optimize
practices. [2 , 3] In contrast, one of the risks of screening by ir-
radiation described above is the induction of radiation-induced
cancers as a function of the dose received by repeated mammo-
grams, particularly in asymptomatic women. [4 , 5] According
to the concordant results of radiobiology studies, a low dose
of irradiation causes DNA breaks. With the absence of DNA
repair in mammary epithelial cells, these eects are increased,
especially in women at risk, if they undergo controls by repeated
mammographic examinations. [6–8]
During 2015 and 2016, 1.1 and 1.5 million women were
screened, respectively, according to the latest progress report
in Morocco. [9 , 10] In addition, technological advances in the
practice of mammography in Morocco have expanded the range
of X-ray procedures and changed exposure techniques in the
facilities, in particular the gradual replacement of lm mam-
mography by full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) [11] . Digital equipment
oers better image quality but may increase radiation doses if
not optimized. However, the benet of a justied diagnostic
or screening mammogram outweighs the projected radiation-
induced malignancy associated with the mammographic
procedure. Therefore, any medical exposure must be justied
when requested by a qualied physician, especially in screening
mammography. It is important to optimize practices to ensure
a radiation dose as low as reasonably achievable (ALARA) to
avoid unnecessary radiation. [6 , 12 , 13]
In this context, developments in the monitoring aspects of
workers and patients, particularly medical exposures for diag-
nostic or therapeutic purposes, have been signicantly strength-
ened through the consolidation of Moroccan regulations in
terms of radiation protection, with the eorts made by the Mo-
roccan Agency for Nuclear and Radiological Safety and Security
(AMSSNuR) since 2014 [14,30] . The principle of optimizing
delivered radiation doses is the basis of national regulations on
medical exposure [14] . This draft order provides for the use of
diagnostic reference levels as recommended by the International
Commission on Radiological Protection (ICRP) in Publication
135 (2017) [15] ; these regulations and decrees have been pub-
lished or are in the process of being drawn up [16] . While wait-
ing for national DRLs, locally, it is possible to establish DRLs
to compare practices within a hospital, within a unit, or be-
tween hospitals in a region [17] . Local DRLs should conform
with national or regional DRLs established by the competent
authorities, taking into account individual national or regional
circumstances such as availability of equipment and personnel
training.
Studies [18 , 19] show that many countries have estab-
lished DRLs for mammography, but few studies have reported
dosimetry for mammography in Morocco [3 , 10] . The new
ICRP publication recommends that a patient survey is critically
important for establishing DRLs and should not be replaced by
phantom surveys [15] . The ICRP recommends that DRLs be
updated every three to ve years. [20] In practice, the DRLs
are dosimetric indicators of the quality of practices destined to
identify situations requiring corrective action. To quantify the
eectiveness of an optimization approach, [5] they should not
be exceeded without justication for routine procedures.
Until national DRLs for mammography are established in
Morocco, local DRLs can be determined at the facility level, as
recommended by the IAEA. Therefore, this study proposes the
establishment of local DRLs used in full-eld digital mammog-
raphy (FFDM) and tomosynthesis (DBT) in Moroccan health
facilities to guide Moroccan practice.
Methods and materials
Data collection
Three mammography centers in the capital Rabat were se-
lected for this study. Center 1 was a mobile FFDM breast can-
cer screening unit (a reference center), center 2 was a diagnostic
unit with FFDM, and center 3 was a diagnostic unit with to-
mosynthesis. Data collection was retrospective on a total of 146
patients (66 screening and 80 symptomatic) aged 45 years and
older, who visited one of the three mammography centers. The
collection period took place between June 2021 and October
2021.
Data extracted from the mammograms included patient
anatomical data, namely compressed breast thickness (CBT)
in mm, patient age, exposure parameters including kVp, mAs,
projections, anode/lter pairs, compression force, and average
glandular dose (AGD) in mGy.
Mammograms were performed in auto-lter mode. The
mammographic procedures consisted of two bilateral projec-
2 M. Ta l b i , M.E. Mansouri, O. Nhila et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Ta lbi, M.E. Mansouri, O. Nhila et al., Local diagnostic reference levels (LDRLs) for full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) procedures in Morocco, Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2022.03.008
ARTICLE IN PRESS
JID: JMIR [mNS; March 29, 2022;22:2 ]
tions. These projections were craniocaudal (CC) and mediolat-
eral oblique (MLO). Data collection was through uniform and
straightforward forms per similar international studies [21] and
did not involve additional radiation exposure to patients, nor
did it aect facility workow. Quality control checks were per-
formed for all three centers before data collection.
AGD calculation
Three dosimetric quantities can be used to establish DRLs
in mammography. The rst is the incident Air Kerma (IAK),
the second is the entrance surface dose (ESD), and the third
is the average glandular dose (AGD). The choice of the dosi-
metric quantity depends mainly on local practices and regula-
tory requirements. However, because of the radiosensitivity of
mammary glandular tissue, AGD is considered the most rel-
evant quantity [22] and is widely used and recommended by
the ICRP [15] and the International Atomic Energy Agency
(IAEA) [23] . AGD can be displayed directly on the mammog-
raphy machine or calculated via examination parameters such as
kV, mAs, breast compression thickness, and anode/lter torque,
as well as intrinsic machine parameters such as tube output. The
AGD was collected retrospectively from the three mammogra-
phy systems in this study.
Data analysis
The collected data were analyzed using software (Statistical
Package for Social Sciences version IBM SPSS 20) through the
qualitative variables of the average distribution of the AGD ob-
served for each projection on a representative sample of patients
in each center. The median was considered to compare cen-
ters, and the third quartile (75 °percentile) was considered their
DRL. Finally, as dened by the ICRP, the values obtained were
tabulated against the recommended DRLs for digital mam-
mography in other countries.
The personal data of patients were not collected and the
analysis of dose data was performed with condentiality.
Results
A total of 146 women were investigated at three mammog-
raphy facilities for a clinical investigation related to breast ma-
lignancy. The average age of the patients was 52.64 (years), and
the compression force was 158.79 N. Currently, there are no in-
stitutional or national guidelines for compression force in Mo-
rocco.
The mean values, standard deviation (SD), and ranges for
kVp, mAs, and compressed chest thickness (CBT) for all pro-
jections and by center are presented in Table 1 .
The mean, median, range, and 75 °percentile for AGD for
all projections and by center are shown in Table 2 .
Table 3 presents the DRL (mGy) value for this study and
compares it with levels in other countries. In this table, the lo-
cal DRLs for the three facilities included in this study were ac-
ceptable and sometimes lower than those reported in previous
studies in other countries, including the United Kingdom and
Japan.
Discussion
Despite the increasing number of mammography facilities
in Morocco, few studies have addressed the diagnostic reference
levels of radiological examinations (CT, X-ray and mammogra-
phy) [16,27,30–32] . Therefore, this study aims to establish lo-
cal DRLs in mammography for the most frequent procedures
in Morocco.
This study recorded variability in mean tube voltage for
all projections and by center, as shown in Table 1 . The av-
erage kVp values recorded were similar to those recorded in
the studies of Tahir i et al. with a value of 30.74 kV, [3] and
slightly higher than Boujemaa et al. with a value of 29.1 kV,
[10] but signicantly higher than Dzidzornu et al. with a
value of 27.8 [21] . These dierences could be attributed
to variations in equipment, exposure techniques, and breast
thickness.
The average tube current (mAs) used in this study ( Table 1 )
for all projections and by center was lower than that used in pre-
vious studies [3 , 10 , 21] . Dierences may be due to equipment
specications or models, mAs range, and breast thickness. The
tube current of the MLO projection is higher for all centers and
individual centers than the CC projection. This is consistent
with the ndings of Dzidzornu et al., who explained the higher
radiation absorbed due to the inclusion of thicker and stier
structures in MLO projections. This claim is evoked by several
studies that showed a stronger positive correlation between the
tube current of the MLO projection and the CBT [21 , 28] . In
the current study, there is a signicant dierence in tube cur-
rent between digital mammography systems and tomosynthesis
(similarly reported by Te o h et al.) [11] .
The mean compressed breast thickness (CBT) values
recorded in this current study were 55 mm, similar to those
recorded by Boujemaa et al. [10] ; however, it is much higher
than the results reported by Dzidzornu et al. in Ghana with a
value of 40 mm [21] . The dierences could be attributed to
age range since the women included in this study had an age
range of 45 to 79 years while the study in Ghana was 35 to 87
years. In addition, mammography screening also starts earlier
in Ghana [21] .
Variability in applied AGD between centers for the CC pro-
jection; indeed, Center 3 recorded the highest median AGD
(1.7 mGy), followed by Center 1, which recorded a median
value of (1.3 mGy). The least was Center 2 with a median
score of (0.9 mGy). Similarly, there was variability in the AGD
applied between centers for the MLO projection; Center 3
recorded the highest median AGD (1.8 mGy), followed by
Center 1 with a median value of (1.4 mGy), and nally, Center
2 recorded the median value of (0.9 mGy).
The mean AGD recorded in this study for the three centers
and by individual center reported in Table 2 , was (1.47 mGy)
for all centers, and (1.42 mGy) and (1.64 mGy) for the CC
and MLO projections respectively. The mean AGD was higher
M. Ta l b i , M.E. Mansouri, O. Nhila et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx 3
Please cite this article as: M. Ta lbi, M.E. Mansouri, O. Nhila et al., Local diagnostic reference levels (LDRLs) for full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) procedures in Morocco, Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2022.03.008
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JID: JMIR [mNS; March 29, 2022;22:2 ]
Table 1
The Mean and SD of kVp, mAs, and compressed breast thickness of patients in the present study.
Centers kVp mAs CBT (mm)
Mean SD Min-Max Mean SD Min-Max Mean SD Min-Max
All 30,12 1,2 26-34 69,69 1,4 22-189 55,18 3,4 29-79
CC 30,24 1,2 67,64 1,4 53,92 3,4
MLO 30,03 1,2 71,57 1,4 56,48 3,4
Center 1 29,16 1,1 26-32 96,24 1,5 22-189 61,08 2,2 29-79
CC 28,87 1,1 94,69 1,5 56,34 2,2
MLO 29,55 1,1 97,06 1,5 65,83 2,2
Center 2 27,76 1,4 26-31 84,5 1,6 25-107 51,68 2,8 34-73
CC 27,66 1,4 84,04 1,6 50,9 2,8
MLO 27,78 1,4 89,67 1,6 52,51 2,8
Center 3 33,4 1,1 28-34 24,78 1,4 4-43,3 55,7 4,1 33-72
CC 34,1 1,1 20,2 1,4 54,52 4,1
MLO 32,76 1,1 26,5 1,4 55,11 4,1
Table 2
The Median, Mean, Min, Max, and the 75 °percentile distribution of AGD (mGy) in the present study.
Centers Median Mean Min-Max 75th
percentile
All 1,3 1,47 ±0,3 0,47-3,63 1,7
CC 1,2 1,42 ±0,2 1,6
MLO 1,3 1,64 ±0,3 1,8
Center 1 1,4 1,51 ±0,3 0,47-2,85 1,7
CC 1,3 1,34 ±0,4 1,5
MLO 1,4 1,65 ±0,5 1,8
Center 2 0,9 1,18 ±0,3 0,78-2,67 1,3
CC 0,9 1,06 ±0,2 1,2
MLO 0,9 1,26 ±0,2 1,3
Center 3 1,8 2,07 ±0,3 1,13-3,63 2,3
CC 1,7 1,96 ±0,2 2,2
MLO 1,8 2,28 ±0,3 2,3
Table 3
Comparison of the DRL value of AGD (mGy) between this study and other countries.
Examinations This Study United Kingdom [24] Japan [25] Ta hir i et al. [3] Ghana [21] Sri Lanka [26]
All 1,7 2,5 2,4 - 2,0 2,0
CC 1,6 - - 1,32 1,6 -
MLO 1,8 - - 1,34 2,4 -
for center 3 (2.07 mGy) than centers 1 and 2 (1.51 mGy
and 1.18 mGy), so it has been noted that the DBT dose is
high compared to full eld digital mammography. Several stud-
ies showed that the radiation dose of DBT is slightly higher
than that of digital mammography, [11 , 29] and Teoh et al.
found that DBT doses are 24.7% higher than FFDM due to
the combination of several projection images [11] . The mean
AGD recorded in this study for the three centers (reported in
Table 2 ), was higher than that recorded for previous stud-
ies in Morocco, Tahir i et al. CC (1.09 ±0.45) and MLO
(1.26 ±0.74) and Boujemaa et al. CC (0.9 ±0.4) and MLO
(1.1 ±0.5). The variations observed could be attributed to the
experiences of the practitioners and the dierent techniques
and modalities used, as well as to dierences in breast size or
glandularity. Younger or premenopausal women have denser
breast tissue than women older than 50 years; this contrasts
with the results of Dzidzornu et al. [21] .
The AGD 75 °percentile values are considered to be the
DRL in this study. Center 3 recorded the highest DRL (75 °
percentile) of (2.3 mGy) followed by Center 1 (1.7 mGy) and
the lowest value is Center 2 (1.3 mGy), as reported in Table 2 .
Table 3 shows a comparison between the DRLs of the cur-
rent study and the DRLs of previous studies in other coun-
tries [3 , 21 , 24–26] . The DRL value of this study is consistent
with other studies from other countries, with the exception of
the study by Tahir i et al. The dierence between the current
study and the study conducted by Tahir i et al. is the inclusion of
tomosynthesis in the current study, which increased the mean
AGD, and consequently the DRL values. The lower recorded
DRL values compared to other studies could be attributed to
variation in exposure techniques, equipment used and breast
thickness.
Due to the continuous improvement of mammographic
imaging system technology, an assessment of patient doses dur-
4 M. Ta l b i , M.E. Mansouri, O. Nhila et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx
Please cite this article as: M. Ta lbi, M.E. Mansouri, O. Nhila et al., Local diagnostic reference levels (LDRLs) for full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) procedures in Morocco, Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2022.03.008
ARTICLE IN PRESS
JID: JMIR [mNS; March 29, 2022;22:2 ]
ing mammography is essential to evaluate practice and ensure
compliance with national diagnostic reference levels, to im-
prove practice in Morocco, as well as the implementation of
a national quality control program for radiology facilities.
Study Limitations
This study had a limited sample size; the established DRLs
were implemented at only three Moroccan mammography cen-
ters and included data from only 146 patients. Future studies
may consider including a larger number of patients and increas-
ing the number of centers involved.
Conclusion
The present study can be seen as a preliminary to establish-
ing DRLs for mammography in Morocco, which are essential
for dose optimization in digital mammography practice.
Government authorities could conduct a national program
to establish national DRLs and encourage health professionals
to get involved in collecting and compliance with diagnostic
reference levels to evaluate and optimize their practices. There-
fore, it is necessary to conduct training and information pro-
grams and implement a quality assurance program to ensure
that doses are maintained at a level compatible with optimal
image quality.
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M. Ta l b i , M.E. Mansouri, O. Nhila et al. / Journal of Medical Imaging and Radiation Sciences xxx (xxxx) xxx 5
Please cite this article as: M. Ta lbi, M.E. Mansouri, O. Nhila et al., Local diagnostic reference levels (LDRLs) for full-eld digital mammography (FFDM) and
digital breast tomosynthesis (DBT) procedures in Morocco, Journal of Medical Imaging and Radiation Sciences, https://doi.org/10.1016/j.jmir.2022.03.008
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