Digital Breast Tomosynthesis

6/10/2011
THE OPEN UNIVERSITY
A MODERN BREAST CANCER SCREENING AND DIAGNOSIS TOOL: DIGITAL BREAST TOMOSYNTHESIS
Imaging in Medicine S809 | Eleni Pitri
A modern breast cancer screening and diagnosis tool: DIGITAL BREAST TOMOSYNTHESIS
Imaging in Medicine S809 Eleni Pitri
Table of Contents 1. Introduction .......................................................................................................................................... 3 1.1 Scope and Topic Area ...................................................................................................................... 3 1.2 Project Aim and Objectives ............................................................................................................. 3 1.2 Structure of the Report ..................................................................................................................... 4 2. Literature Review ................................................................................................................................. 5 2.1 Progress of Breast screening and diagnosis ..................................................................................... 5 2.2 Conventional X-ray Mammography ................................................................................................ 6 2.2.1 Conventional X-ray Mammography Principles ...................................................................... 6 2.2.2 Disadvantages of Conventional Mammography ..................................................................... 7 2.3 Digital Breast Tomosynthesis (DBT) .............................................................................................. 8 2.3.1 The Development of Tomosynthesis ...................................................................................... 9 2.3.2 Basic Technologic Principles of DBT .................................................................................. 10 2.3.3 DBT Technical Considerations ............................................................................................. 12 2.3.4 Detector Requirements.......................................................................................................... 14 2.3.5 Radiation Dose ...................................................................................................................... 16 3. DBT Clinical Trials Comparison with Conventional Mammography ....................................... 16 3.1 The Potential Advantages of DBT in clinical Practice .................................................................. 16 3.2 DBT clinical Trials ......................................................................................................................... 17 4. Discussion............................................................................................................................................ 23
5. Conclusion ........................................................................................................................................... 25 References .................................................................................................................................................. 26
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1. Introduction:
1.1 Scope and Topic Area Breast cancer is the most frequent type of cancer and the second leading cancer type for estimated deaths among the women in U.S.A.1. It is proved that screening and early detection of breast cancer may contribute to the successful treatment of the disease. At the moment, X-ray mammography, Analog or Full Field Digital Mammography (FFDM) are used in routine clinical practice for screening and have contributed to the reduction of breast cancer mortality. Since the implementation of the flat-panel digital detectors, a new valuable tool is available for screening and diagnosing breast cancer, that is, Digital Breast Tomosynthesis (DBT). Despite the other competing technologies such as Ultrasonography, contrast enhanced MRI and Breast CT, Digital Breast Tomosynthesis is more likely to replace conventional mammography as it may be considered as an improvement of the current FFDM. 1.2 Project Aim and Objectives The aim of this project is to understand DBT technology and critically analyze the advantages and limitations of the technique. In particular the effort will be focused on comparing conventional X-ray Mammography with the literature results of DBT clinical case studies. The project objectives can be summed up as follows: Review of the progress in breast screening and diagnosis Familiarization with Tomosynthesis imaging technique
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Review of the existing literature on DBT Analysis of the results of clinical case studies Comparison of DBT with conventional X-ray Mammography Interpretation of the results obtained
1.3 Structure of the report Chapter 2: Literature Review This chapter presents the major aspects of theoretical background related to X-ray Mammography and Breast Tomosynthesis Chapter 3: DBT Clinical Trials A comparison with Conventional Mammography At this point the clinical case studies reported in literature are analyzed and compared. Chapter 4: Discussion The results obtained by the literature review are summarized and issues that arise from the potential use of DBT into clinical practice are discussed. Chapter 5: Conclusions
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2 Literature Review
2.1 Progress of Breast Screening and Diagnosis Ever since early attempts to use X-rays took place, for the diagnosis of breast cancer, a great progress has been made in the area. In 1913, the first mammograms were taken by Albert Salomon at mastectomies and few years later Mammography was used in-vivo2. In 2000 the first FFDM system gained the first approval by the U.S Food and Drug Administration (FDA) and, since then, Analog Mammography has been replacing. In the last decade, a new X-ray tool for breast screening and diagnosis has been developed, that of DBT. In addition to X-ray
investigating techniques, other modalities such as MRI and Ultrasound have been added to the breast cancer diagnosis methods. Nowadays, apart from the techniques showing anatomical changes, investigating tools based on functional changes have been introduced.
Analog Mammography CR- Mammmography FFDM Anatomic Changes DBT Ultrasound Elastography Contrast enhanced MRI Physio-pathological Changes
CEDSM
CEDBT
Cellular Metabolic Changes
Figure 1: A schematic diagram showing the progress of breast screening and diagnosis. Where CR = Computed Radiography, MRI = Magnetic Resonance Imaging, CE-DSM = Dual-Energy Contrastenhanced Digital Subtraction Mammography and CE-DBT = Dual-Energy Contrast-enhanced Digital Breast Tomosynthesis Page 5 of 28
2.2 Conventional X-ray Mammography 2.2.1 Conventional X-ray Mammography Principles: X-ray mammography is proved to be an efficient technique for screening and diagnosing breast cancer at an early stage. Currently both Analog and FFDM Mammography systems are used in clinical practice. However, in the last decade most of the analog systems with screen-film cassettes have been replaced. Image creation in conventional mammography is based on X-ray attenuation. The mammograms must image the contrast between similar soft tissues (e.g. fat, blood vessel and soft tissues with different density), thus, low kV is required to maximize photoelectric effect and make tissues differences distinguishable.
X-rays Compression paddle Breast Detector

Figure 2: In conventional Mammography the X-ray tube, the compressed breast and the detector are stationary, while one image is obtained from one projection3.
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During the scan, the breast is compressed between the compression paddle and the stationary breast support. The compression evens out the breast thickness and achieves better visualization of tissues and abnormalities, less radiation dose to the patient and reduction of scattering. Furthermore, compression is used to prevent patient motion that causes image blurring. The views most frequently used in conventional screening mammography are craniocaudal (CC) and mediolateral oblique (MLO), whereas in diagnostic cases other views are also used4.
2.2.2 Disadvantages of Conventional Mammography: Although conventional Mammography is an efficient modality which provides reasonably high sensitivity, high resolution and low patient dose, a disadvantage may be traced in terms of receiving a 2D imaging of a 3D object. The attenuated beam which arrives on the flat-panel detector (or the screen film cassette in case of analog system) is proportional to the total attenuation of all the structures between the X-ray tube and the detector (Figure 3). This causes an overlap between structures leading to potential loss of information, sensitivity and specificity. This limitation of conventional Mammography complicates the interpretation of mammograms; it further deteriorates the detection of breast cancer and renders the localization of abnormalities difficult. The consequence is that, in cases of questionable findings, even where findings prove benign, further examinations are needed in order to investigate them and this may cause additional anxiety to patients let alone additional costs.
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Figure 3: In conventional mammography overlapping structures may lead in loss of information (hidden objects of interest), this effect is eliminated in the 3D Breast Tomosynthesis. (Image captured from Smith et al3)
2.3 Digital Breast Tomosynthesis Digital Breast Tomosynthesis (DBT) is a new tool which is expected to address these key limitations of mammography and has the potential efficacy to replace conventional mammography. DBT is similar to X-ray mammography. It is also based on X-ray attenuation, but, instead of 2D images, it reconstructs a number of planar projections providing 3D information. The DBT device is, in most cases, based on the existing digital mammography system; patient positioning during image acquisition is very similar to conventional digital mammography, but the required image reconstruction differs. DBT is a type of limited angle CT with low radiation dose to the patient, similar to that of mammography. Comparably to 2D mammograms, the reconstructed breast images produced by DBT reduce potential false diagnosis due to structure overlapping and increases cancer localization and delineation of borders.
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2.3.1 The development of Tomosynthesis: Tomosynthesis is not a newly invented technique. The conception of the technique goes back to 1930s when Ziedes des Plantes introduced the theory of limited angle tomography only its implementation was not possible5. Digital detectors made the implementation of Tomosynthesis feasible and in 1972 Grant made up the term Tomosynthesis. At this early stage the limitations of digital detectors obstruct trials from taking place for the clinical use of the technique. From late 1980s to late 1990s Tomosynthesis was almost abandoned due to the development of spiral CT which seemed to dominate over all 3D X-ray imaging. Until flat-panel detectors were introduced in late 1990s, clinical applications were not feasible. Full-filled flat panel detectors are characterized by low noise, high frame rate and high detective quantum efficiency (DQE) which are required for a reasonable acquisition time of several (low dose) projections used in Tomosynthesis systems. Over the last years Tomosynthesis clinical applications have increased and improved. The applications which gather most interest are Breast Tomosynthesis and pulmonary nodule imaging. The interest in Breast Tomosynthesis has been further growing after the U.S. FDA approved the first Breast Tomosynthesis System in February 2011.
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2.3.2 Basic technologic principles of Digital Breast Tomosynthesis As mentioned before, the DBT device in almost all commercial systems is combined with the existing digital mammography system. Similarly to conventional mammography the breast is compressed between the compression paddle and the stationary breast support which contains the digital detector. The integrated systems can take a conventional mammogram and a Tomosynthesis set of slices at the same compression.
Figure 4: Schematic representation of DBT operation principles6.
There are more than one motion geometries of the tube and the detector for Tomosynthesis image acquisition5. In current DBT systems, the partial isocentric motion is used (Shown in Figure 5). The X-ray tube moves in an arc about the compressed breast during the exposures while the detector is fixed, and a number of projections are obtained. This type of geometry is preferable because it may more easily be integrated into the current Digital Mammography Systems.
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Figure 5: Schematic representation of partial isocentric motion (captured from Dobbins et al5)
During image acquisition there are two methods of moving the tube. The first one is the stepand-shoot method that the tube completely stops and shoots at each position. The second is the continuous exposure method where the tube moves continuously and the exposures are low dose short pulses. Both methods are not without advantages and disadvantages; yet currently the second method is preferred due to the faster scan times it provides. The projection data obtained by the scan are reconstructed into a series of high resolution images aligned in parallel to the breast platform, perpendicular to the X-ray beam. Because of the limited scan angle there is less resolution in the axis of X-ray beam and higher resolution in the perpendicular plane. The number of images is proportional to the breast thickness and the distance between them. The most frequent spacing is 1mm. The set of images are transferred and read at a common workstation where the radiologist can interpret the reconstructed images.
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2.3.3 DBT Technical Considerations As mentioned above DBT reconstructs images which provide 3D information but, as a result of the limited scan angle, the depth or out-of-plane resolution is low. This limitation of DBT produces out-of-plane artifacts such as the streak artifact of Figure 67. This type of artifact is prominent in visualization of calcifications with DBT. As shown in Figure 6, it does not only degrade the image quality of the focus plane but reduces the visualization in neighboring slices as well. This artifact can be reduced by increasing the scan angle and therefore increasing the depth resolution.
Figure 6: A calcification is seen in four different slices due to an out-of-plane artifact and therefore reduces the visualization in these slices: (a) in focus plane; showing the in-plane black artifact below and above the high contrast calcification, (b) 6 mm from the focus plane, (c) 10 mm from the focus plane and (d) 17 mm from the focus plane. The tube motion is parallel to the streak artifact from top to bottom. (Image captured from Tingberg et al7)
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The optimal scan angle of the tube must be estimated according to a number of factors; the appropriate depth resolution is only one of them. Another factor to be taken into consideration is the scan time. Wider scan angle demands longer scan time, which increases the probability of motion artifacts. Given that the detector is fixed, the field of view is also influenced by wide scan angles and may lead to missing tissues. Furthermore, wide scan angles produce thicker effective breast that induces noise and scattering. Other issues negatively affected by wide angle range are the in-plane and detector resolution. The number of projection is another technical issue for DBT. The optimal number of projection is also depended on several parameters such as: The scan angle: serves to avoid reconstruction artifacts. A number of projections per degree-scan-angle is required referred as projection sampling. Scan time must be kept as short as possible thus can become a limiting factor for the number of projections considering the limited frame rate of detectors.
Large numbers of projections may induce electronic noise.
In current systems the number of projections varies from 11 to 49 and the scan angle of the tube from 150 to 5008. Each manufacturer has used different methods and reconstruction algorithms to develop a DBT system, thus different optimal scan angle and number of projections are received. Table 1 gives the scan angle of the DBT systems provided by four manufacturers; each of them uses a different method.
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Figure 7: DBT systems by four different manufacturers. (A) Siemens Mammomat Inspiration9 (B) GE Breast Tomosynthesis10 (C) Hologic- Selenia Dimensions11 (D) Giotto - IMS12
Table 1: Differences among commercially available DBT systems Manufacturer Name Total scan angle 500 250 150 400 (non uniform distribution) Projections Detector
Siemens GE Hologic* Giotto
MAMMOMAT Inspiration GE Breast Tomosynthesis Selenia Dimensions IMS
25 9 15 11
a-Se CsI a-Se a-Se
*Hologic: Selenia Dimensions is the first commercially available system that gained the FDA approval in February 2011.
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2.3.4 Detector Requirements: One of the most essential parts of the DBT system is the full-field flat-paned detector. Due to the low dose of the exposures, high detective quantum efficiency (DQE) and low noise are required. Because of the numerous projections high frame rate is also essential. The detectors used in most of the current DBT systems are selenium-based but cesium iodide (CsI) crystals based on amorphous silicon are also suitable. Selenium has the highest DQE at the low energies of mammography, more than 95% X-ray absorption. This allows imaging at radiation doses as low as those used in DBT.
2.3.5 Radiation Dose The radiation dose to the patient is a critical consideration for Mammography system manufacturers and regulators. Radiation dose to the patient and image quality are related and must be used in an optimum way. The current DBT systems are within the Mammography Quality Standards Act (MQSA)13 limits which are set at 3 mGy per exposure. The limits concern the Mean Glandular Dose (MGD) at a phantom of a standard breast for a single CC view. The MGD of a single view DBT examination, as they are calculated in early clinical studies, is equal or slightly higher than that of a single view FFDM. As Teerstra et al14 and Good et al15 have reported in their studies, the MGD of DBT system is almost equal to that of FFDM; the first has reported 1.74 mGy and the latter 2 mGy.
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3 DBT Clinical Trials Comparison with Conventional Mammography

3.1 The potential advantages of DBT in clinical practice DBT is a new tool developed to contribute to the detection and diagnosis of breast lesions, especially in women with dense breast tissue. The set of reconstructed images from different angle projections allows visualization of thin breast sections and provides more detailed information for breast structures (normal tissues and abnormalities). Theoretically, DBT has superior sensitivity compared to 2D X-ray Mammography. DBT is expected to provide improved detection of lesions, even to allow detection of small cancers not visualized by conventional mammography. DBT has the capability to provide more information on the margins of a mass and characterize the abnormalities more accurately. Thus, the specificity of the technique is increased while the false-positive recalls are reduced. The numerous potential benefits of DBT clinical use must be proved and evaluated in large randomized clinical trials. The sensitivity and specificity of the technique, in the different types of breast abnormalities, should also be evaluated during clinical trials.
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3.2 DBT clinical trials Recent DBT clinical trials aim to give an early evaluation of the DBT technique. The findings from these studies have generally shown a superiority of DBT in the detection and border determination of masses. In the detection of calcification there are several opinions and the physicians preferred technique is still questionable. The main problem with calcifications detection is that calcifications are dispersed in space; therefore 1mm thick DBT slice may include only a small number of calcifications, making the calcification cluster less perceptible. These early studies have concluded that DBT cannot provide 100% sensitivity and specificity. However, most of them have agreed that it can provide improved sensitivity and specificity. Finally, all of the studies have shown that DBT demands considerably longer reading times by the physician. This major limitation of DBT over conventional mammography is expected to be balanced. First because of the reduction of diagnostic examinations resulting out of an improvement in recall rates. Second because of the familiarization of physicians with the new technique that is expected to reduce the interpretation times. One of the first clinical studies was that of Poplack et al16; the aim of whose project was the comparison between diagnostic DBT and film-screen mammography in a group of 98 women recalled to be examined after a digital screening mammogram. The results have shown that the DBT image quality was equal (51 subjects) or superior (37 subjects) to screen-film mammography in 89% of the cases. A percentage of 11% was assessed to be inferior to screenfilm mammography, calcifications were reported at 73% of these cases. Masses showed better image quality on DBT in a considerable higher amount of cases (68%) or equal quality in 26% of
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them. Among the conclusions of the project was that DBT with FFDM in screening has the potential to reduce the recall rate and the reduction was estimated to 40%.
Analog Mammography
DBT
Photomicrograph
Figure 8: Left breast of 84-year old woman16. (A)Focal compression view: irregular mass is shown by arrows (B)Single slice of DBT: Irregular shaped mass with its margins is shown by arrows and central fat by circle (C)Arrows show infiltrating lobular carcinoma with central fat deposition
Another early clinical study was that of Good et al15; 9 physicians evaluated the image quality of 30 cases for three different modes: FFDM, 11 projections acquired for DBT before the reconstruction and the reconstructed DBT slices. The results are similar to those of Poplack et al; they have shown that the reconstructed DBT images were significantly better in 23% of cases, somewhat better in 44% of cases, comparable in 31% of cases and inferior in only 1.9% of cases. Good et al also estimated the readout times of DBT (2.7 min per examination) and FFDM (1.6 min per examination) and verified that the read out times were longer in the case of DBT examinations.
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Gur et al17, using 8 experienced radiologists and 125 cases (35 with verified findings of cancer and 90 with no findings) assessed the image quality of four different display conditions: FFDM alone, 11 low dose projections, reconstructed DBT images and combined FFDM with DBT. The investigators found that the sensitivity of DBT alone was similar to that of the combination of DBT with FFDM (93%) and the sensitivity of FFDM alone was non-significantly reduced (88%). The specificity of combined DBT with FFDM was the greatest (0.72) compared to DBT alone (0.64) and FFDM alone (0.60). Gur et al have concluded that the combination of DBT with FFDM would have led to 30% reduction of recall rate for cancer free examinations compared to FFDM alone; slightly lower than that of Poplack et al. Using of DBT alone would have diminished the recall rate by 10%. The time to view and rate images was also evaluated for each mode; as it is seen in Table 2 the longest mean time was for the combined mode. The results for FFDM and DBT are slightly lower than those estimated by Good et al, though the difference between the two modes is still almost the same.
Table 2: Mean Time for all readers and examinations to view and rate images from each imaging display mode. Data taken by Gur et al17.
Mode
Mean Time per Examination (min) 1.22 1.38 2.05 2.39
Standard Deviation
FFDM alone Frame DBT Combined FFDM and DBT
1.15 0.99 1.46 1.65
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Rafferty et al18 were the first to produce a large multi-centre trial to compare and analyze the results of FFDM alone and FFDM with combinations of CC and MLO views of DBT. They used the Receiver Operating Curve (ROC) method to analyze data from 310 subjects and 15 readers. As it is shown in Figure 9 there is significant improvement in ROC performance in both fatty and dense breasts when the combination of FFDM with DBT views was used. It is also notable that the ROC performance of combined FFDM with DBT in dense breasts is superior to FFDM alone, not only in fatty dense breasts but also in fatty breasts. These results support the opinion that DBT would improve the detection of breast lesions in women with dense breast tissue. However, the best performance is still for fatty breasts. The investigators have shown a reduction in recall rates for cancer free cases of 43% in fatty breasts and 34% in dense breasts when using combined FFDM with DBT compared to FFDM alone. Estimations close to those stated by Gur et al and Poplack et al.
Figure 9: ROC curves of FFDM alone and combination of FFDM and DBT for fatty and dense breasts. It is shown that the combination of the two modalities is better than FFDM alone both for dense and fatty breasts.
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Teerstra et al14 compared the diagnostic images from FFDM and DBT of 513 cases. As opposed, to the majority of clinical trials, this study has concluded that DBT is as good as FFDM and is not superior in detection of breast cancer. Estimations for sensitivity showed that the two modes had almost the same sensitivity (92.9%). The specificity of FFDM (86.1%) was slightly better than DBT (84.4%). It is also important to note that this study found DBT to be as good as FFDM in detection of malignant calcification (all clusters were detected by using both techniques) which is also to be contrasted with the results of the majority of studies. Helvie et al, as it is presented in a recent paper6, assessed the DBT capabilities in delineation of masses margins (all cases were scheduled for biopsy.) The comparison of DBT with conventional Mammography showed that DBT was better in determination of the perimeter of masses: 77% of the perimeter of a mass could be visualized by DBT and only 53% by FFDM.
Figure 10: Invasive ductal cancer 6 : The cancer of this case is only apparent in the CC view of conventional mammography. On the other hand DBT (1mm thick slice) provides information not only for the cancer but also for the margins at both views.
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Helvie et al assessed the Maximum Intensity Projection (MIP) images of DBT in the detection of microcalcifications. MIP images are 1 or 2 cm thick slices specially reconstructed from DBT examinations in order to overcome the problem of calcifications dispersion in several DBT slices (Figure 11). The investigators have shown that calcification clusters were visible by DBT MIP images in 100% of cases, based on conventional mammography results. It is worth noting that the visualization of calcification was slightly less when 1 mm thick DBT slices were examined (96% for benign and 97% for malignant cases).
Figure 11: Ductal carcinoma in situ is shown by arrows as a microcalcification cluster6. (A) CC view of FFDM (B) 11 mm thick MIP image of DBT. The MIP image of a DBT examination shows the calcifications as good as FFDM.
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4 Discussion
The positive early results from clinical trials justify the positive reactions for DBT by the majority of radiologists. However, prior to further induction of DBT in clinical practice the considerations and questions arising from DBT use must be investigated. Not only the superiority but also the cost-effectiveness and the utility of the technique must be proved during large randomized clinical trials. What seems to be important is to first determine the best use of DBT into routine clinical practice. It is expected to be very useful at both diagnostic and screening level, but it is still questionable whether it is feasible to be used in both cases. The early studies have shown that due to its improved visualization of overlying structures and improved delineation of masses margins, DBT has an important role to play in diagnostic applications. Also DBT has the capability to more accurately determine the type of abnormalities. The use of DBT in screening is more complicated. DBT has a major disadvantage compared to conventional mammography; it demands significantly longer interpretation times by the physician. This disadvantage must be overcome by the benefits of DBT in screening. In order to conclude about the utility of DBT in screening; it is important to accurately evaluate the recall rates biopsy rates and the specificity of DBT in large-scale clinical trials. The high specificity of DBT may be proved enough to improve current diagnostic procedures and patients may go directly for biopsy after a DBT screening. Another important consideration arising from DBT clinical use is the number of views which need to be acquired. So far it has not been clarified whether DBT should be performed in both CC and MLO view or in only one of the two. It is not even clarified whether it should be used
Page 23 of 28
alone or as an adjunctive to FFDM. The majority of studies have shown a weakness of DBT in the detection of calcifications in favor of the opinion that a static view should also be taken (FFDM view or an analogous MIP image). The results from the large multi-centre study of Rafferty et al, were also in consonance with this opinion. They have shown that one DBT view adjunctive to FFDM can provide higher sensitivity and specificity than FFDM alone. The efficient use of DBT will require substantial training, by the physician. The non-familiarity of physicians with DBT images induces the risk of an initial increase in recall rates due to normal tissues that look different and suspicious. In addition physicians familiarity with DBT is essential not only for interpreting the DBT examinations but also for minimizing the interpretation times.
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Conclusion
DBT is an outstanding new development for screening and diagnosing of breast cancer. The initial results from early clinical studies are in favor of the new technique, especially in the case of masses. The evaluation of calcifications is still questionable and needs further investigation. So far it has not been clarified whether DBT should be used alone or as an adjunctive to FFDM However, the early results reveal that DBT alone or as an adjunctive will significantly contribute in the improvement of current breast cancer screening and early diagnosis by decreasing recall rates and false positive biopsies. It is essential to confirm these early results with large randomized clinical trials. An important advantage of DBT, over other competing technologies, is that its basic technology is X-ray mammography. It can be integrated in the existing installed systems; it uses the existing familiar digital radiologic equipment and seems to be easily accepted by patients and health care professionals. All these factors create a positive prospective that DBT may overcome the barriers, which it currently faces, and finally will become a cost-effective, low dose imaging modality in the field of mammography.
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References
1
American
Cancer
Society
(2011)
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and
Figures
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[online],
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2
Gold, R.H., Basset, L.W. and Widoff, B.E. (1990) Highlights from the History of Mammography,
Radiographics, vol. 10, p.p. 1111-1131.

3
Smith, A. (2011) Design Considerations in Optimizing a Breast Tomosynthesis System [online], (assessed July
http://www.hologic.com/data/Design_Considerations_Optimizing_Breast_Tomo.pdf 2011).
4
Radiology Info (2011) Mammography [online], http://www.radiologyinfo.org/en/info.cfm?pg=mammo
(assessed Augast 2011)

5
Dobbins III, J.T. and Godfrey, D.J. (2003) Digital X-ray Tomosynthesis: Current state of the art and
clinical potential, Physics in Medicine and Biology, vol. 48, pp. R65-R106.
6
Helvie, M.A. (2010) Digital Mammography Imaging: Breast Tomosynthesis and advanced application,
Radiologic Clinics of North America, vol. 48, no. 5, pp. 917-929.

7
Tingberg, A. (2010) X-Ray Tomosynthesis: A review of its use for breast and chest imaging,
Radiation Protection Dosimetry, vol. 139, no. 1-3, p.p. 100-107.

8
Dobbins III, J.T. (2009) Tomosynthesis imaging: At a translational crossroads Medical Physics, vol.
36, no. 6, pp/ 1956-1967.

9
Siemens (2009) 3D Tomosynthesis with MAMMOMAT Inspiration [online],
http://www.medical.siemens.com/siemens/en_GLOBAL/gg_sps_FBAs/files/Mammo_Brochures/WS_M AMMOMAT_Inspiration_Tomo_DRUCK_engl_0907.pdf (Assessed July 2011) Page 26 of 28
10
GE Healthcare (2011) GE Breast Tomosynthesis Smith, A. (2011) Fundamentals of Breast Tomosynthesis System [online],
11
http://www.hologic.com/data/WP-00007_Tomo_08-08.pdf (assessed July 2011)

12
Giotto(2010) The new Dimensions in Digital Mammography [online],
http://www.imsitaly.com/downloads/GiottoBrochure.pdf (Assessed July 2011)

13
U.S. Food and Drug Administration (FDA) (2009) Mammography Quality Standards Act Regulations
[online], http://www.fda.gov/RadiationEmittingProducts/MammographyQualityStandardsActandProgram/Regulations/ucm110906.htm#s90012 (assessed Augast 2011).

14
Teerstra, H. J., Loo, C. E., van den Bosh, M. A. A. J, van Tinteren, H., Rutgers, E.J.T., Muller, S.H.
and Gilhuijs K.G.A. (2010) Breast Tomosynthesis in clinical practice: initial results, European Radiology, vol. 20, pp. 16-24.
15
Good, W. F., Abrams, G. S., Catullo, V. J., Chough, D. M., Canott, M. A., Hakim, C. M. and Gur, D
(2008) Digital breast tomosynthesis: A pilot observer Study, American Journal of Roentgenology, vol. 190, p.p. 865869.
16
Poplack, S.P., Tosteson, T.D., Kogel, C.A. and Nagy, H.M. (2007) Digital Breast Tomosynthesis:
Initial Experience in 98 Women with Abnormal Digital Screening Mammography, American Journal of Roentgenology, vol. 189, p.p. 616-623.
17
Gur, D., Abrams, G. S., Chough, D.M., Gannot, M.A., Hakim, C.M., Rerrin, R.L., Rathfon, G.Y.,
Sumkin, J.H., Zuley, M.L. and Bandos, A.I. (2009) Digital breast Tomosynthesis: observer performance study, American Journal of Roentgenology, vol. 193, p.p. 586-591.
Page 27 of 28
18
Rafferty, E.A., Smith, A.P. and Niklason, L.T. [Radiologic Society of North America 95th Scientific
Assembly and Annual Meeting] (2009) Assessing radiologist performance in dense versus fatty breasts using combined full-field digital mammography and breast Tomosynthesis compared to full-field digital mammography alone [online], http://rsna2009.rsna.org/search/event_display.cfm?em_id=8016152 (Assessed Augast 2011).
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6/10/2011

THE OPEN UNIVERSITY

Imaging in Medicine S809 | Eleni Pitri

Cellular Metabolic Changes

X-rays Compression paddle Breast Detector

Figure 4: Schematic representation of DBT operation principles6.

Large numbers of projections may induce electronic noise.

Siemens GE Hologic* Giotto

MAMMOMAT Inspiration GE Breast Tomosynthesis Selenia Dimensions IMS

a-Se CsI a-Se a-Se

3 DBT Clinical Trials Comparison with Conventional Mammography

Mean Time per Examination (min) 1.22 1.38 2.05 2.39

FFDM alone Frame DBT Combined FFDM and DBT

1.15 0.99 1.46 1.65

http://www.cancer.org/Research/CancerFactsFigures/CancerFactsFigures/cancer-facts-figures-2011, (assessed July 2011).

Radiographics, vol. 10, p.p. 1111-1131.

Radiology Info (2011) Mammography [online], http://www.radiologyinfo.org/en/info.cfm?pg=mammo

(assessed Augast 2011)

Radiologic Clinics of North America, vol. 48, no. 5, pp. 917-929.

Radiation Protection Dosimetry, vol. 139, no. 1-3, p.p. 100-107.

36, no. 6, pp/ 1956-1967.

Siemens (2009) 3D Tomosynthesis with MAMMOMAT Inspiration [online],

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