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Breast Tomosynthesis

Posted Sep 30, 2011 Updated Apr 10, 2023
By Jay A. Baker MD , Joseph Y. Lo PhD
18 min read

Standard analog mammography is a screening success story with the proven capacity to reduce mortality from breast cancer . Conventional full-field digital mammography (FFDM) has improved the ability to detect breast cancer in select patient populations . Unfortunately, the accuracy of both analog and digital mammography remains low, with sensitivities reported at 36%–70% depending on breast tissue density and recall rates for many practitioners remaining well above the 5%–10% target range .

A fundamental reason for missed breast cancer is overlapping breast tissue, which can conceal or obscure important features of malignancy . Overlapping tissue is also a frequent cause of false-positive findings which require additional imaging, radiation exposure, expense, and anxiety for patients without added health benefit . Breast tomosynthesis is a new imaging technique designed to eliminate the issue of overlapping tissue. This new technique has the potential to reduce false positive exams while maintaining equal, or possibly improved, sensitivity for detecting breast cancer.

Development of digital tomosynthesis

Digital tomosynthesis uses conventional x-rays and a digital detector to create tomographic cross-sectional images or “slices” of a volume of tissue. These slices are typically thin, with only a 1-mm thick plane of tissue in sharp focus; tissue above and below this plane is out of focus. These thin slices largely eliminate the issue of confusing overlapping tissue often evident on conventional projection mammography and may therefore improve the accuracy of breast imaging.

In contrast to conventional mammography, the tube head of a tomosynthesis system is engineered to move in an arc over the breast, while numerous low-dose projection images are obtained ( Fig 1 ). Data from these low-dose projection images are then manipulated using reconstruction algorithms similar to computed tomography (CT) scans to produce thin-slice cross-sectional images through the breast . Because the system is a modified digital mammography unit ( Fig 2 ), tomosynthesis images can be obtained in any orientation that can be obtained with conventional mammography including craniocaudal (CC), mediolateral oblique (MLO), and true lateral orientations.

Figure 1, Schematic of digital breast tomosynthesis device. Breast held in position by compression paddle. X-ray tube pivots in arc above breast. Low-dose projection data obtained during single acquisition are reconstructed into multiple thin in-focus slice images.

Figure 2, Clinical system for breast tomosynthesis (Hologic Selenia Dimensions) is a modified full-field digital mammography platform. Motorized tube head moves in arc over compressed breast during acquisition.

Each of the cross-sectional slices created in digital tomosynthesis is parallel to and at different heights above the detector like conventional tomography . Conventional geometric tomography creates a single in-focus image by moving the x-ray tube and detector in synchrony about the patient, with the in-focus plane determined by the fulcrum of motion . A conventional tomography exam requires a separate acquisition—and, therefore, a separate exposure to ionizing radiation—for each in-focus plane. In contrast, digital tomosynthesis produces tomographic “slices” of an entire tissue volume using a single acquisition and single radiation exposure. The radiation dose for a tomosynthesis exam is therefore similar to that for a single conventional mammographic image .

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Technical features of digital tomosynthesis

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Table 1

Technical Specifications for Several Breast Tomosynthesis Systems

GE Hologic Selenia Dimensions Siemens MAMMOMAT Inspiration Target/filter Rh/Rh W/Al W/Rh Detector CsI /a-Si a-Se a-Se Pixel pitch (μm) 100 140 (70 μm @ 2× binning) 85 Acquisition time (seconds) 7 4 25 Scan angle (degrees) 25 15 45 Scan motion Step and shoot Continuous Continuous Number of projection images 9 15 25 Dose (vs. full-field digital mammography) 100% 120% 100-200% Reconstruction Simultaneous algebraic reconstruction technique Filtered backprojection Filtered backprojection Reconstructed slice thickness (mm) 0.5-1 1 1

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Digital Detectors

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Reconstruction Algorithms

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Digital Storage Requirements

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Compression

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Computer-aided Detection

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Multimodality Approach

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Imaging overview

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Normal Anatomy

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Figure 3, Comparison of normal anatomy on conventional digital mammogram and digital breast tomosynthesis in 52-year-old woman. (a) Conventional digital mammogram in mediolateral oblique projection demonstrates subcutaneous blood vessels, pectoralis muscle, and axillary lymph nodes overlapping fibroglandular breast tissue in single projection image. (b) Single slice of digital breast tomosynthesis exam in mediolateral oblique orientation demonstrates superficial aspect of far lateral breast including mole marker on skin and stippled appearance of fat in recesses of skin (89) . (c) Mediolateral oblique tomosynthesis slice through central breast. Fatty hila of all visible axillary lymph nodes ( arrows ) are more evident than on screen-film mammogram. Pectoralis muscle fibers with interspersed fat now sharply in focus. Parenchyma in central-lateral breast is in focus. (d) Mediolateral oblique tomosynthesis slice through medial breast. Pectoralis muscle is out of focus, whereas parenchyma in central-medial breast is now in focus. Parallel lines at top of image are an artifact of reconstruction ( arrows ).

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Artifacts

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Figure 4, A 59-year-old woman with degenerated calcified fibroadenoma in the medial right breast. (a) Single slice from tomosynthesis exam of right breast in craniocaudal orientation. Coarse calcification characteristic of benign degenerated fibroadenoma ( circled ) in medial breast. Black “embossed” appearance on either side of calcification is artifact because of reconstruction algorithm. Note nipple is sharply in focus indicating precise location of circled calcification at the 3 o’clock position. (b) Tomosynthesis image from more inferior breast below level of coarse calcification demonstrates multiple repeating out-of-plane “ghost” images ( circled ). Note out-of-plane blurred appearance of nipple.

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Benign breast lesions

False-positive Mammogram

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Figure 5, Comparison of false positive film-screen mammogram with corresponding tomosynthesis in 70-year-old woman. (a) Craniocaudal projection conventional digital mammogram demonstrates an apparent focus of architectural distortion ( circled ) for which patient was recalled from screening exam for additional mammographic views. (b-d) Single tomosynthesis slices in the craniocaudal orientation demonstrating normal fibroglandular tissue over 8 mm ( circled ) that superimposes to form the apparent architectural distortion questioned on the film-screen mammogram.

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Cyst/Fibroadenoma

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Figure 6, Comparison of appearance of fibroadenoma in 45-year-old woman on film-screen mammography and digital breast tomosynthesis. (a) Craniocaudal film-screen mammogram demonstrates an obscured mass in the medial right breast ( arrow ). Subsequent needle core biopsy confirmed diagnosis of fibroadenoma. (b) Single slice from breast tomosynthesis exam performed in craniocaudal orientation better delineates well-circumscribed margins around entire fibroadenoma ( arrow ).

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Malignant breast lesions

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Figure 7, A 62-year-old woman with invasive ductal carcinoma of superior medial right breast. (a) Craniocaudal view conventional digital mammogram demonstrates mass largely obscured by overlying breast parenchyma ( arrow ). (b) Mediolateral oblique view conventional digital mammogram. Only very subtle architectural distortion visible at site of malignancy ( arrow ). (c) Craniocaudal projection tomosynthesis image clearly demonstrates round, spiculated mass ( arrow ). (d) Mediolateral oblique projection tomosynthesis image demonstrates subtle but visible irregular mass with associated architectural distortion ( arrow ).

Figure 8, Comparison of appearance of invasive ductal carcinoma in the medial left breast on conventional digital mammogram versus digital tomosynthesis in a 57-year-old woman. (a) Conventional digital mammogram craniocaudal view demonstrates oval obscured mass in medial left breast ( arrow ). (b) Single image from craniocaudal digital breast tomosynthesis exam demonstrates spiculated rather than obscured margin of this invasive ductal carcinoma ( circled ).

Figure 9, A 69-year-old woman with 6-mm invasive ductal carcinoma of superior mid right breast. (a) Conventional mammogram mediolateral oblique view. Exam was interpreted as normal. Location of architectural distortion subsequently identified on tomosynthesis is noted by arrow. (b) Single image from mediolateral oblique digital breast tomosynthesis exam demonstrates more conspicuous architectural distortion ( circle ) representing 6-mm invasive ductal carcinoma.

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Calcifications

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Figure 10, A 59-year-old woman with ductal carcinoma in situ. (a) Conventional mediolateral oblique (MLO) full-field digital mammography demonstrates cluster of calcifications in superior right breast, middle depth ( circled ). (b) Spot compression magnification view better depicts cluster of pleomorphic calcifications. (c) Cluster of calcifications depicted on breast tomosynthesis in MLO orientation ( box ). (d) Close up of cluster of calcifications in boxed area of MLO orientation tomosynthesis image.

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Challenges to clinical adoption of tomosynthesis

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One- versus Two-view Technique

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Radiation Dose

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Interpretation Time

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Calcifications

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Screening versus Diagnostic

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Imaging Protocol

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Other Barriers to Implementation

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Conclusions

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Academic Radiology, Volume 18, Issue 10
Journals General Radiology
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