Breast tomosynthesis: A diagnostic addition to screening digital mammography

Objectives

Comparison between digital mammography alone and with adding digital breast tomosynthesis in breast cancer screening.

Comparison between two-dimensional synthetic mammography reconstructed from digital breast tomosynthesis and full-field digital mammography for the detection of T1 breast cancer

Objective

To evaluate the interpretative performance of two-dimensional (2D) synthetic mammography (SM) reconstructed from digital breast tomosynthesis (DBT) in the detection of T1-stage invasive breast cancers, compared to 2D full-field digital mammography (FFDM).

Methods

This retrospective study enrolled 214 patients. For each patient, FFDM and DBT were performed between January and June 2013, and SM was reconstructed from DBT data. Three radiologists interpreted images and recorded visibility scores and morphologies of cancers. Diagnostic performances of SM and FFDM were compared. Percentages of detected cancers and visibility scores were compared for tumour size, and presence of calcifications for each observer.

Results

Observer sensitivity showed no difference for detection with SM and FFDM (P?>?0.05). One observer showed a higher specificity (P?=?0.02) and higher positive predictive value with SM (95 % CI 0.6–16.4), but the differences in the corresponding values between SM and FFDM for the other observers were not statistically significant. In subgroup analyses according to tumour size and presence of calcifications, percentages of detected cancers and visibility scores were not significantly different.

Conclusions

Diagnostic performances of SM and FFDM are comparable for detecting T1-stage breast cancers. Therefore, our results indicate that SM may eliminate the need for additional FFDM during DBT-based imaging.

Key Points

? DBT plus FFDM increases radiation dose compared to FFDM alone.? Detecting T1-stage cancers with only SM is comparable to detection with FFDM.? Two-dimensional SM may replace dose-requiring FFDM in DBT-based imaging.

     

Radiation dose with digital breast tomosynthesis compared to digital mammography: per-view analysis

Objectives

To compare radiation dose delivered by digital mammography (FFDM) and breast tomosynthesis (DBT) for a single view.

Methods

4,780 FFDM and 4,798 DBT images from 1,208 women enrolled in a screening trial were used to ground dose comparison. Raw images were processed by an automatic software to determine volumetric breast density (VBD) and were used together with exposure data to compute the mean glandular dose (MGD) according to Dance’s model. DBT and FFDM were compared in terms of operation of the automatic exposure control (AEC) and MGD level.

Results

Statistically significant differences were found between FFDM and DBT MGDs for all views (CC: MGD_FFDM=1.366 mGy, MGD_DBT=1.858 mGy; p<0.0001; MLO: MGD_FFDM=1.374 mGy, MGD_DBT=1.877 mGy; p<0.0001). Considering the 4,768 paired views, Bland-Altman analysis showed that the average increase of DBT dose compared to FFDM is 38 %, and a range between 0 % and 75 %.

Conclusions

Our findings show a modest increase of radiation dose to the breast by tomosynthesis compared to FFDM. Given the emerging role of DBT, its use in conjunction with synthetic 2D images should not be deterred by concerns regarding radiation burden, and should draw on evidence of potential clinical benefit.

Key Points

? Most studies compared tomosynthesis in combination with mammography vs. mammography alone. ? There is some concern about the dose increase with tomosynthesis. ? Clinical data show a small increase in radiation dose with tomosynthesis. ? Synthetic 2D images from tomosynthesis at zero dose reduce potential harm. ? The small dose increase should not be a barrier to use of tomosynthesis.

     

Dual energy contrast enhanced soft tissue digital mammography versus ultrasound elastography in the evaluation of breast masses

Purpose

To evaluate the value of dual energy contrast enhanced (DECE) soft tissue digital mammography and ultrasound elastography (UE) in the detection of breast lesions and discrimination between benign and malignant ones.

Cost-effectiveness of ultrasound-guided surgical clips placement for breast cancer localization prior to neoadjuvant chemotherapy

Objective

To evaluate the outcome and the cost value of surgical clips use as guidance for breast cancer localization in patients prepared for neoadjuvant chemotherapy (NAC).

Diagnostic value of the stand-alone synthetic image in digital breast tomosynthesis examinations

Objective

To demonstrate the non-inferiority of synthetic image (SI) mammography versus full-field digital mammography (FFDM) in breast tomosynthesis (DBT) examinations.

Methods

An observational, retrospective, single-centre, multireader blinded study was performed, using 2384 images to directly compare SI and FFDM based on Breast Imaging Reporting and Data System (BIRADS) categorisation and visibility of radiological findings. Readers had no access to digital breast tomosynthesis slices. Multiple reader, multiple case (MRMC) receiver operating characteristic (ROC) methodology was used to compare the diagnostic performance of SI and FFDM images. The kappa statistic was used to estimate the inter-reader and intra-reader reliability.

Results

The area under the ROC curves (AUC) reveals the non-inferiority of SI versus FFDM based on BIRADS categorisation [difference between AUC (ΔAUC), -0.014] and lesion visibility (ΔAUC, -0.001) but the differences were not statistically significant (p=0.282 for BIRADS; p=0.961 for lesion visibility). On average, 77.4% of malignant lesions were detected with SI versus 76.5% with FFDM. Sensitivity and specificity of SI are superior to FFDM for malignant lesions scored as BIRADS 5 and breasts categorised as BIRADS 1.

Conclusions

SI is not inferior to FFDM when DBT slices are not available during image reading. SI can replace FFDM, reducing the dose by 45%.

Key Points

? Stand-alone SI demonstrated performance not inferior for lesion visibility as compared to FFDM.? Stand-alone SI demonstrated performance not inferior for lesion BIRADS categorisation as compared to FFDM.? Synthetic images provide important dose savings in breast tomosynthesis examinations.

     

Comparison of the diagnostic performance of digital breast tomosynthesis and magnetic resonance imaging added to digital mammography in women with known breast cancers

Objectives

To compare the diagnostic performance of digital breast tomosynthesis (DBT) and magnetic resonance imaging (MRI) added to mammography in women with known breast cancers.

Methods

Three radiologists independently reviewed image sets of 172 patients with 184 cancers; mammography alone, DBT plus mammography and MRI plus mammography, and scored for cancer probability using the Breast Imaging Reporting and Data System (BI-RADS). Jack-knife alternative free-response receiver-operating characteristic (JAFROC), which allows diagnostic performance estimation using single lesion as a statistical unit in a cancer-only population, was used. Sensitivity and positive predictive value (PPV) were compared using the McNemar and Fisher-exact tests.

Results

The JAFROC figures of merit (FOMs) was lower in DBT plus mammography (0.937) than MRI plus mammography (0.978, P?=?0.0006) but higher than mammography alone (0.900, P?=?0 .0013). The sensitivity was lower in DBT plus mammography (88.2 %) than MRI plus mammography (97.8 %) but higher than mammography alone (78.3 %, both P?<?0 .0001). The PPV was significantly higher in DBT plus mammography (93.3 %) than MRI plus mammography (89.6 %, P?=?0 .0282).

Conclusions

DBT provided lower diagnostic performance than MRI as an adjunctive imaging to mammography. However, DBT had higher diagnostic performance than mammography and higher PPV than MRI.

Key Points

? Digital breast tomosynthesis (DBT) plus mammography was compared with MRI plus mammography. ? DBT had lower sensitivity and higher PPV than MRI. ? DBT had higher diagnostic performance than mammography.

     

The added value of contrast enhanced spectral mammography in identification of multiplicity of suspicious lesions in dense breast

Objective

To evaluate the additive value of Contrast Enhanced Spectral Mammography (CESM) in the preoperative assessment of malignant lesions in dense breast parenchyma regarding multiplicity.

Digital breast tomosynthesis versus digital mammography: a clinical performance study

Objective

To compare the clinical performance of digital breast tomosynthesis (DBT) with that of full-field digital mammography (FFDM) in a diagnostic population.

Methods

The study enrolled 200 consenting women who had at least one breast lesion discovered by mammography and/or ultrasound classified as doubtful or suspicious or probably malignant. They underwent tomosynthesis in one view [mediolateral oblique (MLO)] of both breasts at a dose comparable to that of standard screen-film mammography in two views [craniocaudal (CC) and MLO]. Images were rated by six breast radiologists using the BIRADS score. Ratings were compared with the truth established according to the standard of care and a multiple-reader multiple-case (MRMC) receiver-operating characteristic (ROC) analysis was performed. Clinical performance of DBT compared with that of FFDM was evaluated in terms of the difference between areas under ROC curves (AUCs) for BIRADS scores.

Results

Overall clinical performance with DBT and FFDM for malignant versus all other cases was not significantly different (AUCs 0.851 vs 0.836, p?=?0.645). The lower limit of the 95% CI or the difference between DBT and FFDM AUCs was ?4.9%.

Conclusion

Clinical performance of tomosynthesis in one view at the same total dose as standard screen-film mammography is not inferior to digital mammography in two views.     

Estimation of percentage breast tissue density: comparison between digital mammography (2D full field digital mammography) and digital breast tomosynthesis according to different BI-RADS categories

Objective:

To compare breast density estimated from two-dimensional full-field digital mammography (2D FFDM) and from digital breast tomosynthesis (DBT) according to different Breast Imaging–Reporting and Data System (BI-RADS) categories, using automated software.

Methods:

Institutional review board approval and written informed patient consent were obtained. DBT and 2D FFDM were performed in the same patients to allow within-patient comparison. A total of 160 consecutive patients (mean age: 50±14 years; mean body mass index: 22±3) were included to create paired data sets of 40 patients for each BI-RADS category. Automatic software (MedDensity^©, developed by Giulio Tagliafico) was used to compare the percentage breast density between DBT and 2D FFDM. The estimated breast percentage density obtained using DBT and 2D FFDM was examined for correlation with the radiologists'' visual BI-RADS density classification.

Results:

The 2D FFDM differed from DBT by 16.0% in BI-RADS Category 1, by 11.9% in Category 2, by 3.5% in Category 3 and by 18.1% in Category 4. These differences were highly significant (p<0.0001). There was a good correlation between the BI-RADS categories and the density evaluated using 2D FFDM and DBT (r=0.56, p<0.01 and r=0.48, p<0.01, respectively).

Conclusion:

Using DBT, breast density values were lower than those obtained using 2D FFDM, with a non-linear relationship across the BI-RADS categories. These data are relevant for clinical practice and research studies using density in determining the risk.

Advances in knowledge:

On DBT, breast density values were lower than with 2D FFDM, with a non-linear relationship across the classical BI-RADS categories.To tailor screening and diagnosis protocols, it is important to identify females with an increased risk of breast cancer [1–3]. It has been estimated that females with dense breasts (breast densities of >75%) have 4–6 times higher risk of breast cancer than females with low breast densities [4] and that breast density is increasingly recognised as an independent determinant of breast cancer risk and possibly in prognosis [5]. Assessment of breast density is becoming crucial in epidemiological studies, including the estimation of breast cancer risk and assessing breast density-related risk over time, radiation dose monitoring and monitoring drug-related response [6,7].Different methods and classifications have been reported to assess breast density: the Tabar classification [8], Wolfe''s parenchymal patterns [9], and both semi-quantitative and quantitative computer-aided techniques [10–16]. The Breast Imaging–Reporting and Data System (BI-RADS) classification, considered as the additional quantitative scheme, is routinely used in the USA and was introduced to standardise reporting. Initially, it was based on four qualitative categories but an additional quantitative scheme was added in 2003, based on the extent of fibroglandular tissue [17]. Mammographic breast density estimation may be limited by the two-dimensional (2D) nature of the imaging technique, whereas a three-dimensional (3D) imaging modality, such as digital breast tomosynthesis (DBT), reduces the appearance of the overlapping parenchymal tissue and may therefore influence or alter density assessments [13,14]. In DBT, high-spatial-resolution tomographic images of the breast are reconstructed from multiple low-dose projection images acquired within a limited range of X-ray tube angles [15]. It has been demonstrated in a few studies that the automated estimation of breast density eliminates subjectivity between comparisons of full-field digital mammography (2D FFDM) and DBT and is more reproducible than a quantitative BI-RADS evaluation [14,16]. However, previous research mainly considered patients with relatively high breast density, with the possibility of the results not being applicable across all density categories and showing whether published percentage breast density differences between 2D FFDM and DBT apply to less dense or non-dense breasts. The purpose of our study was to compare the breast tissue density estimated using 2D FFDM and DBT among patients in a balanced data set of the four BI-RADS categories, using fully automated software.     

Digital breast tomosynthesis at screening assessment: are two views always necessary?

Objective:

The current recommendation from the UK National Health Service Breast Screening Programme is that digital breast tomosynthesis (DBT) can be used for further assessment of possible screen-detected soft-tissue abnormalities in place of spot compression views and when used should be performed in two projections. The aim of the study was to assess whether two-view DBT is necessary if the abnormality is seen only in one view on initial full-field digital mammography (FFDM).

Methods:

617 cases with possible masses, distortions and asymmetrical densities visualized only in one view on screening FFDM were included. All of these females underwent two-view DBT, clinical examination and ultrasound. The FFDM and DBT findings on each view were compared and correlated with the histological diagnosis.

Results:

586 of 617 cases had normal or benign findings on further assessment, and no additional information was obtained on the other DBT view. There were 31 confirmed cancers. In 26 cases (84%), the cancer was seen on the corresponding DBT view. No cancer was seen on the other DBT view alone. Five cancers (16%) were not seen on either view on DBT owing to technical reasons. No cancers would have been missed if only the corresponding DBT view was performed.

Conclusion:

Two-view DBT may not be necessary when used for further assessment of possible screen-detected soft-tissue abnormalities. Larger studies should be undertaken to investigate this further.

Advances in knowledge:

One-view DBT may be adequate in assessing soft-tissue abnormalities seen only on one FFDM view.     

Mammographic density estimation: one-to-one comparison of digital mammography and digital breast tomosynthesis using fully automated software

Objective

To compare breast density on digital mammography and digital breast tomosynthesis using fully automated software.

Methods

Following institutional approval and written informed consent from all participating women, both digital breast tomosynthesis (DBT) and full-field digital mammography (FFDM) were obtained. Breast percentage density was calculated with software on DBT and FFDM.

Results

Fifty consecutive patients (mean age, 51?years; range, 35–83?years) underwent both FFDM and DBT. Using a method based on the integral curve, breast density showed higher results on FFDM (68.1?±?12.1 for FFDM and 51.9?±?6.5 for DBT). FFDM overestimated breast density in 16.2% (P?P?r?=?0.54, P?r?=?0.44, P?Conclusion Breast density appeared to be significantly underestimated on digital breast tomosynthesis.

Key Points

• Breast density is considered to be an independent risk factor for cancer
• Density can be assessed on full-field digital mammography and digital breast tomosynthesis
• Objective automated estimation of breast density eliminates subjectivity
• Automated estimation is more accurate than BI-RADS quantitative evaluation
• Breast density may be significantly underestimated on digital breast tomosynthesis

     

Accuracy of CESM versus conventional mammography and ultrasound in evaluation of BI-RADS 3 and 4 breast lesions with pathological correlation

Aim

Assess accuracy of contrast enhanced spectral mammography (CESM) versus conventional mammography and ultrasound in evaluation of BI-RADS 3 and 4 breast lesions with pathological correlation.

Indeterminate breast lesions: Can contrast enhanced digital mammography change our decisions?

Objective

To assess the efficiency of dual energy contrast enhanced mammography in the assessment of the indeterminate breast lesions (BIRADS 3 and BIRADS 4).

The role of breast tomosynthesis in a predominantly dense breast population at a tertiary breast centre: breast density assessment and diagnostic performance in comparison with MRI

Objectives

To compare breast density measured on digital breast tomosynthesis (DBT) (BI-RADS-based breast composition and fully-automatic estimation) and magnetic resonance imaging (MRI) (BI-RADS amount of fibroglandular tissue), and to evaluate the diagnostic performance in terms of sensitivity and specificity of DBT and MRI in a predominantly dense breast population.

Methods

Between 2015 and 2016, 152 women with 103 breast malignancies, who underwent 3-T breast MRI and DBT within 2 months’ time, were enrolled in this study. Breast composition/fibroglandular tissue and findings on DBT (two readers) and MRI were reported using BI-RADS 5th edition. Digital mammography images were analysed for breast percent density (PD) using the Libra software tool.

Results

A majority of women had dense breasts as categorised by breast composition c (heterogeneously dense) (68%) and d (extremely dense) (15%). The mean PD was 44% (range, 18-89%) and the correlation between breast composition and PD was r = 0.6. The diagnostic performance of MRI was significantly higher compared to DBT for one reader as described by the area under the receiver operating characteristic (ROC) curve (p = 0.004) and of borderline significance for the other reader (p = 0.052).

Conclusions

MRI had higher diagnostic performance than DBT in a dense breast population in the tertiary setting.

Key Points

? MRI had higher diagnostic performance than DBT in a dense breast population ? Diagnostic performance of DBT was comparable to MRI in women with fatty breasts ? MRI was superior to DBT in preoperative breast cancer size assessment

     

Diffusion weighted imaging in early prediction of neoadjuvant chemotherapy response in breast cancer

Background

Neoadjuvant chemotherapy (NAC) has clinically important outcome. Early evaluation of the treatment response is important to avoid unnecessary therapy in non-responders. MRI is the most sensitive imaging for monitoring NAC response.

Can the Smart detect™ in breast ultrasound provide a second opinion?

Background

Ultrasound and mammography alone may not always identify malignant breast lesions. Samsung Medison has added the Smart detect? (S-detect?) program to its ultrasound features, and this may improve the identification of benign and malignant breast lesions.

Diffusion weighted (DW) MRI role in characterization of breast lesions using absolute and normalized ADC values

Introduction

Diffusion-weighted imaging (DWI) is a modality that depicts the diffusivity of water molecules. This technique has the potential to play an adjunct role to conventional and dynamic MRI in the assessment of breast tissue.

Comparative study between breast tomosynthesis and classic digital mammography in the evaluation of different breast lesions

Objective

To evaluate the impact of adding 3D Tomosynthesis to Full Field Digital Mammography (FFDM) in the detection and diagnosis of breast lesions.

Subjects and methods

The study included 166 mammograms with indeterminate findings selected from 1600 mammograms. They were classified into two groups: group 1 ‘Diagnostic mammograms’ of symptomatic women and group 2 ‘Screening mammograms’. Dense breasts assigned as ACR3 and ACR4 presented 69% (n = 114/166) of the studied cases. FFDM and 3D tomosynthesis examination was done and imaging findings were evaluated before and after the use of 3D tomosynthesis images.

Results

Both modalities were compared regarding detection and diagnosis, each individually assessed, using the Pearson Chi Square tests. Detection (P value: 0.006) and diagnosis (P value: 0.048) of breast lesions dramatically improved when 3D tomosynthesis images were considered in the evaluation. The sensitivity, specificity, and accuracy of digital mammography was 60%, 20.7% and 48% have significantly enhanced on applying tomosynthesis to be 94.5%, 74% and 89.7%.

Conclusion

Three-dimensional tomosynthesis significantly enhanced the detection and characterization of breast lesions on digital mammography especially in the context of dense breast parenchyma (ACR 3&4).     

Performance of computer-aided detection applied to full-field digital mammography in detection of breast cancers

Objective

The aim of this retrospective study was to evaluate performance of computer-aided detection (CAD) with full-field digital mammography (FFDM) in detection of breast cancers.

Materials and Methods

CAD was retrospectively applied to standard mammographic views of 127 cases with biopsy proven breast cancers detected with FFDM (Senographe 2000, GE Medical Systems). CAD sensitivity was assessed in total group of 127 cases and for subgroups based on breast density, mammographic lesion type, mammographic lesion size, histopathology and mode of presentation.

Results

Overall CAD sensitivity was 91% (115 of 127 cases). There were no statistical differences (p > 0.1) in CAD detection of cancers in dense breasts 90% (53/59) versus non-dense breasts 91% (62/68). There was statistical difference (p < 0.05) in CAD detection of cancers that appeared mammographically as microcalcifications only versus other mammographic manifestations. CAD detected 100% (44/44) of cancers manifesting as microcalcifications, 89% (47/53) as no-calcified masses or asymmetries, 88% (14/16) as masses with associated calcifications, and 71% (10/14) as architectural distortions. CAD sensitivity for cancers 1-10 mm was 84% (38/45); 11-20 mm 93% (55/59); and >20 mm 97% (22/23).

Conclusion

CAD applied to FFDM showed 100% sensitivity in identifying cancers manifesting as microcalcifications only and high sensitivity 86% (71/83) for other mammographic appearances of cancer. Sensitivity is influenced by lesion size. CAD in FFDM is an adjunct helping radiologist in early detection of breast cancers.