Digital film viewer versus conventional view boxes in the identification of bone and joint disorders

PURPOSE: To compare the diagnostic accuracy of a digital film viewer (Smartlight 2000 Plus) versus a conventional view box for the identification of bone and joint disorders. MATERIAL AND METHODS: In order to evaluate the qualitative and quantitative differences of digital and conventional film viewers, 100 plain films of patients with bone and joint disorders taken in an emergency room January through May 1998 were reviewed utilizing both types of view boxes. Three radiologists expert of bone and joint disorders, independently compared the films, filled a form about the qualitative and quantitative analysis of the lesions depicted for each patient, and reported a few notes on the technical quality of the plain films in terms of exposure. The results were compared using the chi-square test (p < 0.005). RESULTS: Data analysis showed that the digital film viewer permitted a quicker reading of the film while decreasing the perception threshold for elementary lesions and ocular fatigue. All the radiographs read with the digital film viewer were considered technically adequate: the film quality was considered good in 10 cases and sufficient in 2. Two of the same radiographs read with the conventional view box were considered of good quality, nine were considered sufficient and one was considered insufficient due to overexposure. There were six cases of agreement and six of disagreement for the diagnosis: four were due to overexposure of the radiograph and two to better conspicuity provided by the digital film viewer. DISCUSSION: Correct image illumination is the first element a radiologist evaluates when reading a radiograph. A conventional view box may, when it is not properly maintained or when the radiograph is overexposed, decrease the radiologist's visual capacity. This increases the time required to read the radiograph and, therefore, physical and ocular fatigue, which in turn increases the risk of missing or misevaluating a lesion. A digital film viewer emits light with a variable intensity which is proportional to the optical density of the film. This increases the visual capacity of the radiologist and the lesion contrast, while reducing the factors which affect the radiograph reading. CONCLUSIONS: The use of a digital film viewer increased the visual capacity of the radiologist and eliminated the negative elements which complicated the radiograph reading and permitted the use of radiographs that would otherwise have been considered of poor quality due to overexposure. This, combined with the experience of the radiologist, decreased of the risk of missing or misevaluating a lesion.     

View box luminance measurements and their effect on reader performance

RATIONALE AND OBJECTIVES: The purpose of this study was to investigate the importance of view box luminance and viewing conditions on low-contrast detection by readers. MATERIALS AND METHODS: Radiographs of a mammographic contrast-detail phantom were examined on 632 view box panels. The luminance of these panels was obtained by using a calibrated meter and ranged from 860 to 3,300 nit. Twelve radiologists reported the number of contrast-detail disks for each size (diameter, 0.3-7.0 mm) deemed to be visible on films with optical densities of 1.00-2.60. Radiologist performance in reading low-contrast phantom images was also studied as a function of room illuminance and image masking. RESULTS: Median luminance was 1,700 nit, with 25- and 75-percentile values of 1,450 and 2,150 nit, respectively. Low-contrast visibility generally was independent of view box luminance, regardless of film density or disk diameter. Low-contrast visibility deteriorated when masking around the image was removed and at normal room illuminance. The greatest deterioration in performance occurred at the highest film densities and with the smallest size disks. CONCLUSION: Detection of low-contrast features on radiographs is relatively independent of view box luminance, but it is degraded by the presence of stray light and by increased room illuminance.     

Radiologists' preferences for digital mammographic display. The International Digital Mammography Development Group

PURPOSE: To determine the preferences of radiologists among eight different image processing algorithms applied to digital mammograms obtained for screening and diagnostic imaging tasks. MATERIALS AND METHODS: Twenty-eight images representing histologically proved masses or calcifications were obtained by using three clinically available digital mammographic units. Images were processed and printed on film by using manual intensity windowing, histogram-based intensity windowing, mixture model intensity windowing, peripheral equalization, multiscale image contrast amplification (MUSICA), contrast-limited adaptive histogram equalization, Trex processing, and unsharp masking. Twelve radiologists compared the processed digital images with screen-film mammograms obtained in the same patient for breast cancer screening and breast lesion diagnosis. RESULTS: For the screening task, screen-film mammograms were preferred to all digital presentations, but the acceptability of images processed with Trex and MUSICA algorithms were not significantly different. All printed digital images were preferred to screen-film radiographs in the diagnosis of masses; mammograms processed with unsharp masking were significantly preferred. For the diagnosis of calcifications, no processed digital mammogram was preferred to screen-film mammograms. CONCLUSION: When digital mammograms were preferred to screen-film mammograms, radiologists selected different digital processing algorithms for each of three mammographic reading tasks and for different lesion types. Soft-copy display will eventually allow radiologists to select among these options more easily.     

Stereotactic excisional breast biopsy performed by interventional radiologists using the advanced breast biopsy instrumentation system

The Advanced Breast Biopsy Instrumentation (ABBI) system, which uses surgical cannulas up to 20 mm in diameter, is an alternative to conventional surgical biopsy for the diagnosis of non-palpable breast lesions. Since the need for radiological skill outweighs the surgical content of the technique, we evaluated the feasibility of complete management of the procedure by interventional radiologists. 35 of the 111 patients originally scheduled for the procedure were excluded, three because the lesion could not be visualized and 32 because of insufficient thickness of the compressed breast. The procedure had to be abandoned in one case due to a technical failure. 77 stereotactic excisional breast biopsy procedures were performed using the ABBI system in 75 patients with suspicious non-palpable mammographic lesions. The procedure was carried out under local anaesthesia in the radiology department, using a dedicated Lorad (R) radiographic system. 31 (40%) masses without calcifications, 11 (14%) masses with calcifications and 35 (46%) clusters of microcalcifications without tumour mass were sampled. 43 (56%) benign lesions and 34 (44%) malignant lesions were diagnosed. The overall mean diameter of the lesions was 8.7 mm (range 3-22 mm). All 34 patients with malignancies and lobular carcinoma in situ subsequently underwent surgery, the results of which are reported. Three (4%) haematomas were detected and aspirated percutaneously. Two technical problems occurred: an ABBI cannula malfunction, and a computer failure of the digital imaging system during the procedure. The average procedure time was 80 min and the cost of each procedure was 2,800,000 Italian lire (1555 US$). It is concluded that tissue sampling with the ABBI system can be performed entirely by radiologists without significant problems. The procedure was well tolerated by all patients. The quality of the biopsy specimen was identical to that of a surgical specimen but with the advantages of stereotactic precision for localization of the lesion.     

Rates and causes of disagreement in interpretation of full-field digital mammography and film-screen mammography in a diagnostic setting

OBJECTIVE: This study was performed to determine the rates and causes of disagreements in interpretation between full-field digital mammography and film-screen mammography in a diagnostic setting. SUBJECTS AND METHODS: Patients undergoing diagnostic mammography were invited to participate in the digital mammography study. Three views, selected by the radiologist interpreting the film-screen mammography, were obtained in both film-screen mammography and digital mammography. Radiologists independently assigned a Breast Imaging Reporting and Data System (BI-RADS) category to the film-screen mammography and the digital mammography images. The BI-RADS categories were grouped into the general categories of agreement, partial agreement, or disagreement. A third and different radiologist reviewed all cases of disagreement, reached a decision as to management, and determined the primary cause of disagreement. RESULTS: Six radiologists reviewed digital mammography and film-screen mammography diagnostic images in a total of 1147 breasts in 692 patients. Agreement between digital mammography and final film-screen mammography assessment was present in 937 breasts (82%), partial agreement in 159 (14%), and disagreement in 51 (4%), for a kappa value of 0.29. The primary causes of disagreement were differences in management approach of the radiologists (52%), information derived from sonography or additional film-screen mammograms (34%), and technical differences between the two mammographic techniques (10%). CONCLUSION: Significant disagreement between film-screen mammography and digital mammography affecting follow-up management was present in only 4% of breasts. The most frequent cause of disagreement in interpretation was a difference in management approach between radiologists (interobserver variability). This source of variability was larger than that due to differences in lesion visibility between film-screen mammography and digital mammography.     

Features of non-small cell lung carcinomas overlooked at digital chest radiography

PURPOSE: To examine the imaging features of non-small cell lung carcinomas (NSCLC) overlooked at digital chest radiography (dCXR), and compare general and thoracic radiologists' performance for lung carcinoma detection at dCXR. METHODS: Frontal and lateral dCXR from 30 consecutive patients with lung carcinoma overlooked during initial interpretation and 30 normal controls were independently retrospectively reviewed by two blinded thoracic radiologists and, in a separate review, three blinded general radiologists. The location, size, histopathology, borders, presence of superimposed structures, and lesion opacity were recorded. Interobserver agreement was calculated, and the detection performance between thoracic and general radiologists was compared. RESULTS: The average patient age was 67.9 years (range 47-82 years). The average size of carcinomas missed by the thoracic radiologists was 18.1mm (range 10-32 mm). Lesion margins were circumscribed in 29% (2/7), and 71% (5/7) of missed lesions were obscured by anatomical superimposition. Seventy-one percent (5/7) of missed lesions were solid nodules on computed tomography (CT) images. Forty-three percent of lesions were located in the upper lobes and 63% were adenocarcinomas. Compared with general radiologists, the seven NSCLC missed by the thoracic radiologists tended to be smaller (p=0.063), had significantly lower CT density measurements (-92.4+/-87.5 HU versus -70+/-87.2 HU, p=0.050), and more commonly had an ill-defined margin (p=0.026). The clinical stage of the overlooked lesions did not differ between the two groups (p=0.480). CONCLUSIONS: The lesion size, location, conspicuity, and histopathology impact the likelihood of lung carcinoma detection at dCXR in a fashion similar to that of conventional film-screen techniques.     

Localization of breast lesions identified on only one mammographic view

Occasionally, a breast lesion is visible in only one mammographic projection. A simplified method of using parallax in a dedicated mammographic system has been devised to locate accurately lesions that are not visible in two orthogonal projections. In eight patients, a parallax approach from essentially a single mammographic position was used to place a hookwire preoperatively at nonpalpable suspicious abnormalities detected by mammography. Needles were inserted parallel to the chest wall while the breast was compressed in the mammographic unit. In each case, the tissue containing the lesion was pierced by a needle chosen to be longer than the distance from the skin to the abnormality. Simple geometric ratios were used to determine the position of the lesion along the needle shaft after slightly changing the mammographic projection and viewing the needle obliquely. In all cases, this parallax approach permitted accurate localization of the lesion.     

Initial experience with the advanced breast biopsy instrumentation device.

OBJECTIVE: The Advanced Breast Biopsy Instrumentation (ABBI) device (United States Surgical; Norwalk, CT) is designed to percutaneously excise nonpalpable breast lesions. Because this is a new technique, we report our initial experience with regard to technical success, complications, and histologic margins for malignancies. SUBJECTS AND METHODS: From May 14, 1997, until March 4, 1998, 89 consecutive patients elected to undergo the ABBI procedure. Preprocedure imaging included screening mammography and additional mammographic and sonographic studies when deemed necessary. Lesions were targeted by the surgeons. Specimen radiography was performed for all lesions, and the images were interpreted by radiologists. Pathologic analysis was provided or reviewed by a dedicated breast pathologist. Parameters analyzed included technical success, complications, lesion size, histologic diagnosis, and margin status for malignant lesions. RESULTS: There were 29 patients with 30 noncalcified masses, 53 patients with clustered calcifications, three patients with masses and calcifications, three patients with asymmetric densities, and one patient with architectural distortion. Eighteen ABBI procedures were aborted, converted to core biopsy, or failed to remove the targeted lesion. Fifteen patients experienced a total of 19 complications; 10 of the complications required treatment and follow-up after the biopsy. Of 11 malignant tumors revealed by ABBI, four had negative margins. Seven of these 11 malignant tumors had positive margins. CONCLUSION: The ABBI procedure had a high number of complications and technical failures and did not reliably provide cancer-free margins for malignant tumors. Women with nonpalpable breast lesions that need a tissue diagnosis are better treated by stereotactic or sonographically guided needle biopsy.     

An investigation into why two-view mammography is better than one-view in breast cancer screening

AIM: To determine why two-view mammography in screening for breast cancer is more effective than using a single medio-lateral oblique view.MATERIALS AND METHODS: In the United Kingdom Coordinating Committee on Cancer Research randomized trial of one- vs two-view mammography in breast cancer screening the oblique view was assessed by one radiologist and two views (oblique and cranio-caudal) assessed by another. For the present study the mammographic films were retrieved from the screening centres and assessed by three consultant radiologists. Mammographic films were available from 110 women; 87 had their breast cancer detected by both one and two views and in 23 it was missed by one view but detected using two views. Outcome measures were breast size, location and size of the cancer, mammographic features, presence of microcalcification and overall radiological assessment.RESULTS: Although 23 cancers were missed in the original trial when one view was used, only two were not visible on the oblique view. Cancers missed using a single oblique view (and only detected if the cranio-caudal view was available with the oblique) tended to be smaller by about 4 mm (P = 0.05), centrally located in the breast (P = 0.16), not spiculated or round, (P 相似文献   

Signal detectability of mammography depends on film-screen system and luminance of view box

High-density film and the high-luminance view-box system are being recommended for mammograms owing to the improved detection of masses. However, this system causes an increase in radiation. Therefore, the purpose of this study was to assess whether the detection of masses would improve using the normal-luminance view box and normal-density film with different types of contrast systems. Low-contrast detection using ROC analysis and high-contrast detection using an ACR phantom were evaluated for the following systems: high-density film and high-luminance view box, normal-density film and normal-luminance view box, and normal-density film with wide latitude and normal-luminance view box. The results showed no significant variation in the detectability of the system with high-density film and high-luminance view box and the normal-density film with wide latitude and normal-luminance view box. However, in terms of low-contrast visibility, the system using normal-density film and normal-luminance view box was significantly reduced in comparison with the others. Therefore, the system with normal-density film with wide latitude and the normal-luminance view box is recommended because of reduced radiation dose.     

Simulating the mammographic appearance of circumscribed lesions

Optimization performance of digital image post-processing techniques in mammography requires controlled conditions of data sets permitting quantitative representation of image characteristics of pathological findings. Digital test objects, although objective and quantitative, do not mimic mammographic appearance and clinical data sets do not provide adequate sets of values of the various pathological finding characteristics. This can be overcome by digital simulation of pathological findings and superimposition on mammographic images. A simple method for simulation of mammographic appearance of radiopaque and/or radiolucent circumscribed lesions is presented. Circumscribed lesions are simulated using grey-level transformation functions which shift and compress the range of the initial pixel grey-level values in a region of interest (ROI) of a digitized mammographic image, according to grey-level analysis in 200 ROIs of real circumscribed lesions from digitized mammographic images. Simulation addresses lesion image characteristics, such as elliptical shape, orientation, halo sign for radiopaque lesions and capsule for radiolucent lesions, and is implemented in a user-driven PC-based interactive application. The appearance of the lesions is evaluated by six radiologists on a sample of 60 real and 60 simulated radiopaque lesions with the use of receiver operating characteristic (ROC) analysis. The area under the ROC curve, pooling the responses of the observers, was 0.55±0.03 indicating no statistically significant difference between real and simulated lesions (p>0.05). The method adequately simulates the mammographic appearance of circumscribed lesions and could be used to generate circumscribed lesion data sets for performance evaluation of image processing techniques, as well as education purposes. Electronic Publication     

Observer variation in the detection of osteopenia

In order to determine observer variation in the detection of osteopenia, 15 pairs of lateral chest radiographs obtained within two weeks of each other were reviewed separately by two radiologists and one orthopedist on three separate occasions. Intra- and interobserver variations were calculated for each individual film and film pairs using Kappa values. The individual observers were not able to give consistent readings on the same film on different days (average Kappa=0.54). When the additional factors of repeat films (average Kappa=0.47), or separate observers (average Kappa=0.38) were analyzed, agreement was even worse. The identification of osteopenia from the lateral view of the thoracic spine is highly subjective and variable from film to film and observer to observer.Presented at the 71st Scientific Assembly of the Radiological Society of North America, Chicago, IL, November 17–22, 1985     

Through the colonoscope--a radiologist's view

A series of 1578 consecutive colonoscopies performed by radiologists in training is reviewed, with specific reference to patients with colorectal neoplasms. The contribution of the radiologist to the practice of colonoscopy is discussed. This input to the colonoscopy service of a hospital carries several benefits, including the following: a link is established between radiologists and gastroenterologists which improves the standard of both barium enema and colonoscopic examinations; informed discussion is made possible about the suitability of a barium enema lesion for endoscopic removal; the endoscoping radiologist acquires an impartial view of each examination and is able to choose the more appropriate investigation; direct visualisation of the colonic mucosa and its abnormalities may facilitate the interpretation of barium radiographs and enhance the quality of the radiological training that can be offered. In our experience, participation in a weekly colonoscopy session has had no adverse effect on the routine work of the radiology department.     

The positive predictive value for diagnosis of breast cancer full-field digital mammography versus film-screen mammography in the diagnostic mammographic population

RATIONALE AND OBJECTIVES: Diagnostic mammography is performed on women with clinical symptoms that suggest breast cancer or women for whom further mammographic evaluation has been requested because of an abnormal screening mammography. We assessed whether the use of full-field digital mammography would improve the positive predictive value (PPV) for the diagnosis of breast cancer in a diagnostic population compared with film-screen mammography. MATERIALS AND METHODS: From January 2002 to December 2003, 11,621 patients underwent diagnostic mammography at the University of North Carolina Hospital, Chapel Hill. Among these 11,621 patients, 1400 lesions in 1121 patients underwent biopsy. We included the biopsy-performed lesions, so PPV3 was used for comparison of PPVs between film-screen mammography and full-field digital mammography. Six breast radiologists interpreted the images using the Breast Imaging Reporting and Data System of the American College of Radiology. PPV3s were compared between film-screen and full-field digital mammography in the entire study cohort and in specified subgroups according to different radiologists, breast density, and lesion type on mammography. The chi(2) and Fisher's exact tests were used for comparison of PPV3s between two modalities of mammography with the Bonferroni procedure for subgroup analysis. RESULTS: In the entire study cohort, PPV3s of full-field digital mammography and film-screen mammography were similar (difference in PPV3,-0.007; 95% confidence interval, -0.081 to 0.068; P = .8602). In predefined subgroups, there was no difference in PPV3 by the radiologist, breast density, or lesion type between two modalities of mammography (P > .005). CONCLUSION: There is no improvement in PPV for the diagnosis of breast cancer with full-field digital mammography compared with film-screen mammography in a large diagnostic population.     

Digital mammographic interpretation by UK radiographer mammographers: A JAFROC analysis of observer performance

IntroductionRadiologists utilise mammography test sets to bench mark their performance against recognised standards. Using a validated test set, this study compares the performance of radiographer readers against previous test results for radiologists.MethodsUnder similar test conditions radiographer readers were given an established test set of 60 mammograms and tasked to identify breast cancer, they were measured against their ability to identify, locate and give a confidence level for cancer being present on a standard set of mammographic images. The results were then compared to previously published results for radiologists for similar or the same test sets.ResultsThe 10 radiographer readers demonstrated similar results to radiologists and for lesion sensitivity were the highest scoring group. The study group score a sensitivity of 83; a specificity of 69.3 and lesion sensitivity of 74.8 with ROC and JAFROC scores of 0.86 and 0.74 respectively.ConclusionUnder test conditions radiographers are able to identify and accurately locate breast cancer in a range of complex mammographic backgrounds.Implications for practiceThe study was performed under experimental conditions with results comparable to breast radiologists under similar conditions, translation of these findings into clinical practice will help address access and capacity issues in the timely identification and diagnosis of breast cancer.     

Image quality of digital mammography images produced using wet and dry laser imaging systems

IntroductionA study was carried out to compare the quality of digital mammographic images printed or processed by a wet laser imaging system and a dedicated mammographic dry laser imaging system.Material and methodsDigital images of a tissue equivalent breast phantom were obtained using a GE Senographe 2000D digital mammography system and different target/filter combinations of the X-ray tube. These images were printed on films using the Fuji FL-IM D wet laser imaging system and the Kodak DryView 8600 dry laser imaging system. The quality of images was assessed in terms of detectability of microcalcifications and simulated tumour masses by five radiologists. In addition, the contrast index and speed index of the two systems were measured using the step wedge in the phantom. The unpaired, unequal variance t-test was used to test any statistically significant differences.ResultsThere were no significant (p < 0.05) differences between the images printed using the two systems in terms of microcalcification and tumour mass detectability. The wet system resulted in slightly higher contrast index while the dry system showed significantly higher speed index.ConclusionBoth wet and dry laser imaging systems can produce mammography images of good quality on which 0.2 mm microcalcifications and 2 mm tumour masses can be detected. Dry systems are preferable due to the absence of wet chemical processing and solid or liquid chemical waste. The wet laser imaging systems, however, still represent a useful alternative to dry laser imaging systems for mammography studies.     

A comparison of digital and screen-film mammography using quality control phantoms

AIM: To compare the performance of a direct digital mammography system with normal-view and magnified-view conventional screen-film methods using quality control phantoms. MATERIALS AND METHODS: Using a Siemens Mammomat((R))3000 and an Opdima((R))digital spot imaging and biopsy attachment, film and direct digital images of two phantoms [DuPont and TOR (MAM)] were obtained under normal operating conditions. These were assessed by three groups of observers with differing expertise - radiologists, radiographers and medical physicists. Each observer was asked to compare the direct digital image with films taken in standard view and magnified view, providing scores for object visibility and confidence. For the digital images, observers were allowed to vary the image presentation parameters. RESULTS: Both phantoms showed that overall the direct digital view and the magnified view film performed significantly better (P < 0.05) than standard view film. For certain small or low contrast objects the differences became very highly significant (P < 0.001). CONCLUSION: Only the TOR (MAM) phantom showed any significant difference between digital and magnified modalities, with magnified views performing better for fine, faint filaments and digital acquisition better for low contrast objects. Almost no difference existed between the three observer groups. Undrill, P. E. (2000). Clinical Radiology53, 782-790.     

Photostimulable phosphor digital radiography of the extremities: diagnostic accuracy compared with conventional radiography

A direct comparison was made between digital and conventional radiographs to assess the relative accuracy of a photostimulable phosphor digital imaging system in detecting and localizing minor trauma in the extremities. Matched sets of images were obtained on 103 patients who came to the emergency department for radiographs of the hand, wrist, foot, or ankle. One set was obtained with a conventional screen/film system. The other set was obtained with photostimulable phosphor digital cassettes. The two sets of images of each patient were independently interpreted by three radiologists in a blinded fashion. The findings of each of these three readers were compared with the consensus opinion of two different radiologists. Receiver-operating-characteristic (ROC) curves were plotted for each of the three readers, areas under the curves were calculated, and true-positive fractions were determined at false-positive fractions of 0.1. Although no significant differences in the areas under the ROC curves for the two imaging systems were detected, conventional radiography showed a slight advantage. However, when true-positive fractions for fracture detection were compared at false-positive fractions of 0.1 a statistically significant difference was shown, with conventional screen/film radiography being more sensitive. This study raises questions about the use of currently available photostimulable phosphor systems for imaging trauma of the extremities and suggests that those systems should not be used exclusively.     

Evaluation of the diagnostic value of a computed radiography system by comparison of digital hard copy images with screen–film mammography: results of a prospective clinical trial

The purpose of the study was to determine prospectively the diagnostic value of a computed radiography (CR) system by comparing mammographic hard copy images with screen–film mammography (SFM). A series of 100 patients, who came for diagnostic investigation, underwent two-view SFM (Lorad M-IV Platinum) and digital mammography with a CR system (AGFA CR system). The images were obtained by double exposure, i.e. same view without removing compression of the corresponding breast. The CR images were processed with dedicated processing for mammography. Six radiologists read sets of SFM and CR images. The primary efficacy parameter was the overall diagnostic value. The secondary efficacy parameters were lesion conspicuity and lesion details (for masses and micro-calcifications), tissue visibility at chest wall and at skin line, axillary details, overall density and sharpness impression and the overall noise impression. These parameters were scored by a 7-point scoring system. “CR non-inferior to SFM” was concluded if the lower confidence interval bound exceeded 80%. The confidence interval for the overall diagnostic value was between 96.4% and 100%. Pooled analysis of the ten features for image quality comparison demonstrated for all but one feature (lesion details of the calcifications) CR non-inferiority to SFM.     

A review of mammographic lesion localisation and work up imaging in Australia in the digital era

ObjectivesTo investigate the use of coned compression with and without magnification in contemporary Australian digital imaging. To describe lesion localisation techniques used for mammographic work up.Key findingsAs digital breast tomosynthesis becomes mainstream, the need for coned compression imaging has reduced, however the need for coned compression with fine focus magnification for assessment of microcalcification remains. Adapting film screen lesion localisation techniques to the digital setting is limited by the need for “true size” 1:1 ratio images for ease of measurement. Both the digital ruler and a grid technique can be used as an alternate.ConclusionAdvances in image acquisition has evidenced a change in imaging protocols for suspicions lesions within the breast with breast tomosynthesis superseding the need for non-magnified coned compression views of the breast. Adaptation of the approaches to localising these lesions in the digital setting has also been necessary.