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Kohanski Issue 1 Article For Website

Digital Breast Tomosynthesis (DBT) provides a series of one mm thick slices through the breast, allowing for a more detailed 3D view. This can help decrease false positives by up to 37% and increase cancer detection by up to 50% compared to conventional mammography. DBT improves evaluation of masses, distortions, and asymmetries by removing overlapping breast tissue. While it increases cancer finding and lowers unnecessary biopsies, DBT requires a longer scan time and results in a small increase in radiation dose compared to standard mammography.

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40 views2 pages

Kohanski Issue 1 Article For Website

Digital Breast Tomosynthesis (DBT) provides a series of one mm thick slices through the breast, allowing for a more detailed 3D view. This can help decrease false positives by up to 37% and increase cancer detection by up to 50% compared to conventional mammography. DBT improves evaluation of masses, distortions, and asymmetries by removing overlapping breast tissue. While it increases cancer finding and lowers unnecessary biopsies, DBT requires a longer scan time and results in a small increase in radiation dose compared to standard mammography.

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Digital Breast Tomosynthesis

Arrives at Backus Hospital


Phillip Kohanski, MD

In July The William W. Backus Hospital installed looks like a normal mammogram machine and gets
Digital Breast Tomosynthesis (DBT) at the Backus compression just as she would with a conventional
Outpatient Care Center in Norwich, CT. The mamm ram e i erence is t at nine separate
radiology team has undergone training as of July low dose images are generated through a short
and will start using the new breast cancer screening arc. The process is longer than for a conventional
technology in August. The second unit will be mamm ram, ut nl t irt t rt five sec n s
installe in lainfiel , C in Au ust, an ill longer. These images are then sent to a computer
be ready to schedule patients at that site by where a mathematical process called iterative
October 1, 2017. reconstruction generates a series of one mm thick
slices through the breast. The series of slices will be
This will raise some questions for the reminiscent of a CT series and is viewed in a similar
practitioners in the area. What is Digital fashion.1
Breast Tomosynthesis? Why do we need Why do we need this fancy technology? I’m sure
it? How does it work? Which patients many of you are aware of the report issued by the
should I send for an exam? What can I US Preventive Task Force concerning breast cancer
expect for results? I will try to answer screening. Criticism was made that mammography
these questions in this article. led to too many false positive exams, thus incurring
harm in the form of unnecessary imaging tests,
Digital Breast Tomosynthesis, also known as a 3D biopsies, and psychological harm. There was also the
mammogram, is derived from plain tomograms criticism that breast cancer was being over diagnosed
performed years ago. These plain tomograms were and over treated.
supplemented by computed tomography, a technical
variant of the plain tomography. Digital Breast Tomosynthesis has been shown to
decrease the number of false positive mammograms
Tomograms are x-ray images made with intentional
when compared to conventional mammography.
blur. The x-ray source is placed on one side of the
It has also been shown to increase the number
patient and the x-ray receptor on the opposite side.
of invasive cancers found when compared to
Both the source and receptor are moved in opposite
conventional mammography.2
directions such that the fulcrum of the motion is
centered within the patient. Any area in front of To understand those changes we need to understand
or behind the fulcrum will be blurred. The area in what we look for in mammograms. Mammograms,
the plane of the fulcrum will be sharp. It is a way like an t er ra , em nstrates i erent ensities
to remove densities out of the plane of interest and The densities displayed on x-ray are air, fat, soft tissue
focus on the densities within the plane of interest. (water) and calcium (metal).
The fulcrum can be moved incrementally through
the patient to generate a series of slices through the What we see is the interface between those densities
patient’s form. or the relative concentration of those densities.
Digital Breast Tomosynthesis images are generated continued on page 11
in a similar fashion. The patient is placed in what
- 10 - TH E O P E N JO URNAL • FALL 017
What we evaluate on mammograms are masses, 2-D image by stacking all of the one mm slices on top of
calcificati ns, arc itectural ist rti ns an as mmetries each other. This reduces the radiation dose by 40-50%.4, 5
Architectural distortion has the highest positive When you look at DBT exam you will see the regular
predictive value for an invasive cancer of all of the 3-D exam. The synthetic 3-D exam (it will look very
mamm rap ic fin in s Bein scure verla in similar to the 2-D exam), has thin one mm slices and
ensit , t e fine strai t tentacles a cancer can e t icker sla s ima es usuall five t ten slices la ere n
i cult t see n c nventi nal mamm rap e ne top of each other). This will be repeated for each breast
mm slices of a DBT exam removes the density obscuring in the CC and MLO projections. The 2-D images are
these speculations. Unfortunately architectural distortion preserved to give a global view of the breast and get an
by a prior biopsy can be misinterpreted as an invasive appreciati n calcificati n r upin s
cancer. This requires a detailed history from the patient.
Overall the higher sensitivity and speciality of DBT will The computational complexity of DBT increases data
result in more accurate diagnosis of invasive cancer. acquisition time and storage costs.

Masses are discrete lesions. As radiologists we evaluate ic patients ill enefit t e m st r m DB


the density, margins and shape of masses. The trouble Intuitively it would seem women with dense breasts
with conventional mammography is that the breast is ul et t e m st enefit, ut it turns ut t ere is a
a 3-D structure so there are densities in front of, and similar improvement in cancer detection and decrease in
behind, the area of interest that may obscure the lesion. false positive mammograms (call backs) in women with
With DBT we display the breast in a series of one mm fatty breasts.6
thick slices to remove the densities obscuring the area Will there be fewer breast ultrasounds? Probably
of interest, thus making it easier to evaluate the density, not. Screening breast ultrasound can still detect
shape and margins of a mass. One word of caution – in mammographically occult cancers in women with
conventional mammography an encapsulated lesion dense breasts missed by conventional and 3-D breast
containing fat was considered benign. In DBT invasive imaging. Any woman with a palpable abnormality will
cancer has been shown to contain fat.3 still need a breast ultrasound. While there will be fewer
Asymmetries are areas of more vague density which mammographic call backs, the abnormalities detected by
sometimes are seen on only a single mammographic tomosynthesis will still require ultrasound characterization
view. Often times this is just a summation artifact from and help in planning biopsies. Although there is a device
overlying structures in the breast leading to an area of to perform stereotactic biopsies in the tomosynthesis
increased density. Many times patients are recalled for machine this technique will not be immediately employed.
additional spot compression views of these areas as well Lesions detected by tomosynthesis will be referred for
as an ultrasound exam to prove that these areas are ultrasound guided biopsies.
merely summation artifacts and not true lesions. What can we expect? A 15-37% decrease in false positive
The improved evaluation of masses (their density, shape mammograms (recalls) and up to 50% increase in breast
and borders) as well as the elimination of summation cancer detection screening.7 g
artifacts contributing to asymmetries has led to a 1
Peppard HR, Nicholson BE, Rochman CM, Merchant JK, Mayo
si nificant re ucti n in t e alse p sitive mamm rams RC, Harvey JA. Digital Breast Tomosynthesis in the Diagnostic
and has reduced the recall rate. Setting: Indications and Clinical Applications. Radiographics;
35:975-990.
u ill n tice i n t menti n calcificati ns in 2
Ibid.
the evaluation of the mammogram. We typically
3
Ibid.
4
Ibid.
evaluate calcificati ns ase n t eir m rp l an 5
Hooley RJ, Durand MA, Philpotts LE. Advances in Digital Breast
istri uti n avin t in slices makes it i cult t see a Tomosynthesis. AJR 2017; 208:256-266.
r upin calcificati ns ic ma lie in i erent 6
Peppard HR, Nicholson BE, Rochman CM, Merchant JK, Mayo
planes. For that reason we still have a conventional 2-D RC, Harvey JA. Digital Breast Tomosynthesis in the Diagnostic
Setting: Indications and Clinical Applications. Radiographics;
mammogram as part of the combined exam. This leads 35:975-990.
to an increase in the radiation dose for the exam by a 7
Hooley RJ, Durand MA, Philpotts LE. Advances in Digital Breast
factor of two (although still obviously within the limits Tomosynthesis. AJR 2017; 208:256-266.
set by MQSA). There is a method to construct synthetic

T HE O P E N J O UR NAL • F AL L 2017 - 11 -

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