9.2 EQUIP Image-Quality Criteria

The September 1, 2025 ARRT Mammography content specifications placed EQUIP under mammographic technique and image evaluation. This section is not the full inspection-policy chapter. It is what “adequate” looks like on the AWS so you can decide repeat, accept, or mark and document before the lead interpreting physician (LIP) ever sees a poor image in a periodic sample.

The Food and Drug Administration’s Enhancing Quality Using the Inspection Program asks whether clinical images continue to meet the facility’s accreditation-body standards. Those standards are the eight attributes in 21 CFR 900.4(c)(2)—the same list the American College of Radiology (ACR) uses for clinical image review: positioning, compression, exposure level, contrast, sharpness, noise, artifacts, and examination identification. The attributes apply to screen-film, FFDM, and DBT. A pretty tomosynthesis cine does not excuse a noisy, motion-blurred acquisition.

Positioning at EQUIP / AWS Level

You are not repeating the entire positioning atlas here. “Adequate” means the image includes the tissue the view is meant to show, without extra body parts replacing breast:

• CC: medial tissue on the receptor, posterior nipple line (PNL) within about 1 cm of the MLO PNL, nipple in profile when possible.
• MLO: pectoralis muscle convex or straight, extending to or below the PNL; inframammary fold (IMF) open; posterior tissue included.

Missing chest wall, a folded IMF, or abdomen occupying the posterior third is a technical repeat if the patient can be repositioned. Documented limitations (wheelchair, pectus, frozen shoulder) may be accepted with a note. That is not permission to release a sloppy image from an able patient.

Tight collimation belongs with scatter control: cone to calcifications on mag views; do not crop posterior tissue on a screening CC just to make the histogram look pretty.

Compression

Adequate compression thins the breast uniformly, reduces scatter and dose, and immobilizes tissue. Inadequate compression looks like:

• Overlapping fibroglandular tissue that cannot be “windowed away”
• Motion blur on one view
• Non-uniform exposure (thin anterior tissue punched out, thick posterior tissue noisy)
• Skin folds pulled into the field because the breast was not lifted taut

If overlap or motion is from under-compression and the patient can tolerate more, repeat. If pain or a hard implant capsule stopped you at a documented limit, mark and document rather than grinding the patient for a number on the readout. EQUIP cares that poor compression is recognized; it does not require you to injure the patient.

Exposure on Digital Images

Forget “too light / too dark” as the primary digital cue.

• Underexposure: grainy, especially in dense regions; calcifications and spiculations sink into noise. Check displayed mAs and any vendor exposure index. Repeating with more photons—or a more appropriate kVp so AEC can finish—is indicated.
• Overexposure: the processed image may still look fine. Clues are an outlier mAs for that thickness, a clipped skin line, or implant/hardware that sat on the AEC cell. Repeat with manual technique or a repositioned sensor; do not “fix it” only by brightening the monitor.

If you would have called a film too light, look for noise on digital. If you would have called a film too dark, look at dose and AEC logic, not only at the pretty grayscale.

Contrast

Adequate contrast means fat and glandular tissue are distinguishable and dense regions are penetrated enough to see through, not merely outlined. Causes of poor contrast include too-high kVp, grid left out on a contact view, scatter from a huge uncollimated field, and under-compression. Digital windowing can mask a mild miss; it cannot restore subject contrast that never reached the detector. If the whole breast is a homogeneous gray after reasonable windowing, change technique and repeat.

Sharpness: Motion Unsharpness Versus Geometric Unsharpness

Sharpness is the EQUIP attribute that fails microcalcifications and spiculated margins. Two operator-controlled blurs look similar until you take a history.

Motion unsharpness is patient or breast movement during a long exposure. It smears trabeculae, skin, and calcifications, often along one direction, and is more common on MLO (arm fatigue, breathing, longer time). Fix: more effective immobilization, shorter time (higher kVp or harder filter), clearer breath-hold coaching, then repeat.

Geometric unsharpness is physics: large focal spot, large object-to-image distance, or magnification with the wrong spot. The blur is not from the patient wiggling. Fix: small spot on the mag platform, breast as close to the receptor as the view allows on contact, no accidental OID from a mag stand left in place.

Repeating without changing geometry will not fix a large-spot mag view. Coaching stillness will not fix a contact-size spot used at 1.8× magnification. Screen-film also had screen-film contact blur; on FFDM the operator-controlled sharpness fails remain motion and geometry.

Noise and Artifacts

Noise on digital mammography is usually quantum mottle from underexposure. It is grain that hides low-contrast masses. EQUIP scores noise separately from artifacts.

Artifacts include anything that is not anatomy and not quantum noise: deodorant specks, hair, clothing, skin folds, grid lines, detector ghosts. Patient-related artifacts are the next section. At EQUIP level, decide whether the artifact overlays tissue that must be interpreted. If yes and it is removable, repeat. If it is a pacemaker generator, it is not a “repeat until gone” problem.

Examination Identification

This is the MQSA label set from 21 CFR 900.12(c)(5), scored as an image-quality attribute. Missing laterality, a view code not near the axilla, or the wrong patient identifier is a correct-and-rerelease problem. It is not optional “nice to have” data. ACR clinical image review still grades labeling; EQUIP uses the same attribute.

Repeat Versus Accept Versus Mark and Document

The interpreting physician (IP)—not the inspector—decides whether an image is of poor quality for EQUIP corrective-action purposes and must have a way to give ongoing feedback to technologists. The LIP is the MQSA-designated physician most responsible for continuous image quality and for including a sample of images each IP (including the LIP) accepted. Your job at the AWS is to keep obviously inadequate images out of that pile.

Daily interpretation of every case is not the same as the facility’s periodic EQUIP sample review, and repeat-analysis QC is not a substitute for clinical-image review. Those distinctions belong in the policy chapter. What belongs here: if you would be embarrassed to submit the image for ACR clinical image review, do not send it as a finished mammogram.