413
Imaging Physics
Digital Breast Tomosynthesis:
Physics, Artifacts, and Quality
Control Considerations
Nikki Tirada, MD
Guang Li, PhD
David Dreizin, MD
Luke Robinson, MD
Gauri Khorjekar, MBBS
Sergio Dromi, MD
Thomas Ernst, PhD
Abbreviations: ACR = American College of
Radiology, DBT = digital breast tomosynthesis,
FBP = filtered back projection, FDA = U.S. Food
and Drug Administration, FFDM = full-field
digital mammography, MQSA = Mammography
Quality Standards Act, QC = quality control,
3D = three dimensional, 2D = two dimensional
RadioGraphics 2019; 39:0000–0000
https://doi.org/10.1148/rg.2019180046
Content Codes:
From the Department of Diagnostic Radiology
and Nuclear Medicine, University of Mary-
land School of Medicine, 22 S Greene St, Bal-
timore, MD 21201. Presented as an education
exhibit at the 2017 RSNA Annual Meeting.
Received March 5, 2018; revision requested
April 18 and received June 18; accepted June
25. For this journal-based SA-CME activity,
the authors N.T. and D.D. have provided dis-
closures (see end of article); all other authors,
the editor, and the reviewers have disclosed no
relevant relationships. Address correspon-
dence to N.T. (e-mail: pmeteesat@gmail.com).
©
RSNA, 2019
SA-CME Learning Objectives
After completing this journal-based SA-CME
activity, participants will be able to:
■■Describe DBT image acquisition
parameters and their effect on image
quality.
■■Discuss artifacts specific to DBT, why
they occur, and how they can be mini-
mized.
■■Understand QC tasks specific to DBT.
See rsna.org/learning-center-rg.
As digital breast tomosynthesis (DBT) becomes widely used, radi-
ologists must understand the basic principles of (a) image acquisi-
tion, (b) artifacts, and (c) quality control (QC) that are specific to
DBT. Standard acquisition parameters common to both full-field
digital mammography (FFDM) and DBT are combinations of
x-ray tube voltage, current exposure time, and anode target and
filter combinations. Image acquisition parameters specific to DBT
include tube motion, sweep angle, and number of projections.
Continuous tube motion or x-ray emission decreases imaging time
but leads to focal spot blurring when compared with step-and-
shoot techniques. The sweep angle and number of projections de-
termines resolution. Wider sweep angles allow greater out-of-plane
(z-axis) resolution, improving visualization of masses and architec-
ture distortion. A greater number of projections increases in-plane
or x-y axis resolution, improving visualization of microcalcifications.
Artifacts related to DBT include blurring-ripple, truncation, and
loss of skin and superficial tissue resolution. Motion artifacts are
difficult to recognize because of inherent out-of-plane blurring.
To maintain optimal image quality and an “as low as reasonably
achievable” (ALARA) radiation dose, regular QC must be per-
formed. DBT is considered a new imaging modality; therefore,
breast imaging facilities are required to obtain a separate certifica-
tion in addition to that in FFDM, and all personnel (radiologists,
technologists, and medical physicists) are mandated to complete
initial DBT training and maintain appropriate continuing medical
education credits.
©
RSNA, 2019 • radiographics.rsna.org
Introduction
Mammography gained widespread acceptance as a screening tool for
breast cancer detection in the 1970s, after it was shown to reduce
mortality by 25%–52% in randomized controlled trials (1,2). Since
then, technological advancements have driven the evolution from an-
alog film mammography to full-field digital mammography (FFDM)
and digital breast tomosynthesis (DBT). The potential benefits
of using tomosynthesis in breast imaging were recognized in the
mid-1990s, but its use was not practical owing to the poor quantum
efficiency and slow readout times of solid-state image receptors and
limitations in computer processing (3–9). Improvements in flat-panel
detectors from a solid-state design to amorphous selenium (Se) and
amorphous silicon (Si) and cesium (Cs)–iodine (I) detectors and
major advances in computing power led to the first commercially
available DBT unit, Selenia Dimensions (Hologic, Bedford, Mass),
which was approved by the U.S. Food and Drug Administration
(FDA) in 2011 (10,11). Subsequently, other DBT units received
FDA approval, including (in chronological order) SenoClaire (GE
414  March-April 2019 radiographics.rsna.org
Teaching Points
■■ Standard acquisition parameters common to both FFDM and
DBT are x-ray tube voltage, current exposure time, anode
target or filter combinations, and degree of compression.
Parameters that are specific to DBT include tube motion,
sweep angle, and number of projections.
■■ Image resolution at DBT can be defined as in-plane or out-of-
plane resolution. The in-plane, or x-y axis resolution, of DBT is
approximately 100–280 μm, which is comparable to that of
FFDM. Higher in-plane resolution allows better visualization of
small findings such as microcalcifications. Higher out-of-plane
(z-axis) resolution increases depth separation, which improves
visualization of findings with inherently low contrast to sur-
rounding fibroglandular tissue such as masses and architec-
tural distortion.
■■ Commercially available tomosynthesis units currently employ
FBP and iterative reconstruction.
■■ Artifacts specific to DBT include blurring-ripple artifacts, trun-
cation artifacts, and artifacts from loss of skin and superficial
tissue resolution. Grid artifacts and patient motion artifacts
seen at FFDM also can be present at DBT but rarely are appre-
ciated because of the masking effect of out-of-plane blurring.
■■ All personnel including radiologists, technologists, and medi-
cal physicists are mandated to complete 8 hours of initial DBT
training and 15 hours of category 1 continuing medical edu-
cation credits in mammography, with at least 6 hours related
to DBT every 3 years to maintain accreditation. For medical
physicists, the 15 hours of continuing medical education
should include training related to each mammographic mo-
dality under the physicist’s quality assurance oversight.
Healthcare, Waukesha, Wis) in 2014, Mammomat
Inspiration (Siemens Healthineers, Erlangen,
Germany) in 2015, Aspire Cristalle (Fujifilm
Medical, Tokyo, Japan) in 2017, and Senographe
Pristina (GE Healthcare) in 2017 (11).
DBT produces quasi–three-dimensional (3D)
images of the breast, which are reconstructed in
thin sections that allow reduction of anatomic
noise or overlap of fibroglandular tissue. Mul-
tiple large comparative effectiveness studies have
shown that the combination of screening FFDM
and DBT is superior for cancer detection to the
use of FFDM alone, with an increase in detec-
tion rates of 40%–53%, and a reduction in recall
rates of 15%–37% (12–17). FFDM with DBT in
the combination mode allows for better detection
of microcalcification and better comparison with
images from prior examinations. Improvement in
visibility of masses and architectural distortion re-
duces the need for supplemental imaging such as
spot compression views or US as part of the diag-
nostic examination (18–20). However, combined
acquisition of FFDM and DBT has the drawback
of approximately doubling the radiation dose and
increasing image acquisition time. GE Health-
care offers a solution to minimize the radiation
dose by not requiring acquisition of both DBT
and FFDM for each projection (mediolateral
oblique and craniocaudal). Mediolateral oblique
images can be obtained with both FFDM and
DBT, while only FFDM is used to acquire the
craniocaudal view. This method has been shown
to be noninferior for cancer detection at screen-
ing examinations. These concerns were further
addressed when the FDA approved synthesized
two-dimensional (2D) mammography from DBT
datasets to replace FFDM, namely C-View for
Hologic Selenia Dimensions and V-Preview for
GE SenoClaire. Synthesized mammography sim-
ply refers to reconstructions that mimic FFDM.
A 2016 survey (21) of physician members of
the Society of Breast Imaging (SBI) showed that
89% already offered DBT in their practice, and
among respondents who do not have DBT, 62%
were planning to acquire it in the future. How-
ever, this might be an overestimation, because
DBT is less prevalent in nonacademic settings
and smaller practices. The American College of
Radiology (ACR) estimated that approximately
30% of facilities in the United States offered
DBT in 2017 (22). Because substantial increases
in use are expected in the coming years, it is
important to understand how tomosynthesis
images are obtained, recognize artifacts specific
to tomosynthesis, and understand how tomosyn-
thesis quality control (QC) is different from QC
for FFDM. Examples illustrated in this article are
cases from our practice, and images were ob-
tained with Hologic Selenia Dimensions units.
Physical Principles of DBT
In a single view, a technologist can obtain im-
ages in different modes including DBT only, a
combination of DBT and FFDM, a combination
of DBT and synthesized mammography, or all
three. Standard acquisition parameters common
to both FFDM and DBT are x-ray tube voltage,
current exposure time, anode target and filter
combinations, and degree of compression (23).
Parameters that are specific to DBT include tube
motion, sweep angle, and number of projections
(23). Manufacturer-dependent differences in
DBT, such as x-ray tubes, flat-panel detectors,
acquisition parameters, and reconstruction algo-
rithms, are described in full detail in Table 1.
Image resolution at DBT can be defined as
in-plane or out-of-plane resolution. The in-plane,
or x-y axis resolution, of DBT is approximately
100–280 μm, which is comparable to that of
FFDM (24). Higher in-plane resolution allows
better visualization of small findings such as
microcalcifications. Higher out-of-plane (z-axis)
resolution increases depth separation, which
improves visualization of findings with inher-
ently low contrast to surrounding fibroglandular
tissue such as masses and architectural distortion
RG  •  Volume 39  Number 2 Tirada et al  415

Table 1: Currently FDA-approved DBT Systems

Hologic Selenia GE Siemens Fujifilm GE

Parameter Dimensions SenoClaire Mammomat Aspire Senographe
X-ray tube
  Anode target W Mo/Rh W W Mo/Rh
 Filter* Al (700 μm) Mo (30 μm)/Rh Rh (50 μm) Al (700 μm)/Rh Mo (30 μm)/
(25 μm) Rh (30 μm)
  Tube motion Continuous Step and shoot Continuous Continuous Step and shoot
Flat-panel detector
 Detector Amorphous Se Amorphous Si/ Amorphous Se Amorphous Se Amorphous Si/
CsI CsI
  Pixel size (μm) 140 (2 3 2 100 85 150 (ST binned 100
binned) 2 3 1), 100
(HR)
 Grid No Yes No No Yes
Acquisition
  Tube motion Continuous Step and shoot Continuous Continuous Step and shoot
  Sweep angle (degrees) 15 25 50 15 (ST), 40 (HR) 25
  No. of projections 15 9 25 15 9
  Scanning time (sec) 3.7 10 25 9 (HR), 7 (ST) 7
Reconstruction algorithm FBP FBP/ASiR FBP FBP FBP/ASiR
Note.—Al = aluminum, ASiR = adaptive statistical iterative reconstruction, CsI = cesium iodide, FBP = filtered
back projection, HR = high resolution, Rh = rhodium, Mo = molybdenum, Se = selenium, Si = silicone, ST =
standard mode, W = tungsten.
* Some systems use combinations of targets and filters that are specific to DBT and not used for FFDM.

(23,25). Unlike FFDM, DBT provides some
depth information, which improves the conspicu-
ity of lesions and breast tissue, but its out-of-plane
resolution is inferior to that of CT (7,24,26).
Tube Motion
DBT tube motion refers to the mode of x-ray tube
emission with respect to motion of the gantry, with
the use of either a continuous or step-and-shoot
technique. With continuous x-ray tube emission
during gantry rotation, acquisition is partitioned
into a limited number of projections to decrease
noise and increase the signal-to-noise ratio. Con-
tinuous motion has faster imaging times compared
with those of step-and-shoot techniques but has
the disadvantage of focal spot motion blur. Con-
versely, step-and-shoot techniques minimize focal
spot blur, but total acquisition times are longer be-
cause the gantry must come to a complete stop to
avoid motion blur from vibration. The trade-off of
a longer examination time is artifact from patient
motion (10,27).
Sweep Angle
Similar to CT images, tomosynthesis images are
obtained with a moving x-ray source. However,
tomosynthesis images are obtained over a limited
angular range, or sweep angle. The sweep angle
for DBT is 15°–50°, depending on the manufac-
turer. The x-ray tube moves in a symmetric arch
in both a positive and a negative direction around
the center of the detector. For example, with a
sweep angle of 50°, the x-ray source or gantry in a
Siemens Mammomat Inspiration unit moves from
−25° to +25° (28). Given the same radiation dose
and number of projections, a smaller sweep angle
offers better in-plane resolution and visualization
of microcalcifications, and a larger sweep angle
allows better out-of-plane resolution for larger
objects such as masses that occupy multiple planes
(12). Another consideration for determining the
sweep angle is the effect on the field of view. With
wider sweep angles, parts of the breast projection
can exceed the field of view of a stationary detec-
tor, particularly in women with larger breasts (12).
Most DBT units have stationary detectors,
with the exception of the Hologic Selenia Dimen-
sions unit, in which the detectors tilt 5° around
the center of rotation. Given the stationary posi-
tion or nonconcentric movement of the x-ray
tube and detector, truly isotropic geometry is not
achieved at DBT.
Number of Projections
In general, a higher number of projections leads to
better image quality from increased in-plane reso-
lution, decreased out-of-plane blurring for low-
contrast structures, and reduced blurring-ripple
416  March-April 2019 radiographics.rsna.org
artifacts from high-density objects (discussed in
a subsequent section) (12,28). However, DBT is
constrained by radiation dose, which must be kept
in the same low range as that for FFDM. Increas-
ing the number of projections increases the total
radiation dose if the dose per projection is kept
constant; or alternatively results in a lower dose
per projection, which leads to increased image
noise and a poor contrast-to-noise ratio (4,23) if
the total dose is held constant. Each manufacturer
uses a fixed number of projections, optimized on
the basis of sweep angle, radiation dose, and other
acquisition parameters (Table 1) (23).
Radiation Dose
DBT has lower anatomic noise than does FFDM
because of decreased tissue overlap, and affords
the use of higher mean photon energy while
preserving tissue contrast. Most DBT units use a
tungsten (W) anode target with a rhodium (Rh)
or aluminum (Al) filter. The GE SenoClaire and
Senographe Pristina systems use an Rh anode
target and Rh filter. All of these anode target and
filter combinations produce x-rays with higher
mean energy, which leads to a lower average
glandular dose compared with that of analog-film
mammography, but an equivocally to slightly
higher dose compared with that of FFDM.
Increased breast compression thickness leads to
increased average glandular dose for both FFDM
and DBT, but increased breast density has more
effect on the dose for FFDM (29). Combined
use of FFDM and DBT increases the radiation
dose by a factor of 2.25 compared with that for
FFDM-only examinations, but it is still well
within the Mammography Quality Standards Act
(MQSA) guidelines, which mandate a limit of 3
mGy per view (12,30). If FFDM is replaced with
synthesized 2D mammography, the radiation
dose can be reduced by 45% (12,31).
Image Reconstruction
Tomosynthesis imaging data in the Fourier domain
are incomplete owing to the limited sweep angle
and small number of projections, and creating ac-
curate tomosynthesis image reconstructions is chal-
lenging. The nonisotropic geometry degrades z-axis
image resolution, which is derived from the Fourier
domain rather than directly acquired (25,32). The
z-axis resolution is improved by increasing the
range of the sweep angle. However, given dose con-
straints, there is an optimal number of projections
for a certain sweep-angle range beyond which the
in-plane image quality decreases with the number
of projections without any further improvement of
the z-axis resolution (33).
Commercially available tomosynthesis units
currently employ FBP and iterative reconstruc-
tion. Back projection is a conventional algorithm
in which each pixel is created from measured pro-
jections being projected back across the acquisi-
tion angle to create an image. FBP involves the ap-
plication of a convolution filter to each projection
(34). High-pass filters may be applied to improve
sharpness. Iterative reconstruction improves the
image quality by iteratively comparing differences
between the collected data and the current image
estimate and generating new image estimates on
the basis of the differences. Iterative reconstruc-
tion is more computationally expensive, requiring
more advanced computing power and more time,
but its use can greatly reduce noise, or quantum
mottle, while preserving sharpness (35). FBP is
computed rapidly but produces grainy images and
is prone to streak artifacts from surgical or biopsy
clips (33,35).
Reconstructed DBT images are viewed as
multiple thin (0.5–1 mm) sections parallel to the
detector plane. Unlike CT, tomosynthesis section
thickness and reconstruction intervals do not have
a one-to-one correspondence with breast compres-
sion thickness. Summation of multiple sections
into thick-slab images can improve conspicuity
of microcalcifications and allow better delinea-
tion of microcalcification distributions (ie, diffuse,
regional, grouped, linear, or segmental). Subtle
amorphous calcifications may be better visualized
with synthesized mammography (Fig 1a, 1b) and
thin-section DBT (Fig 1c). Studies (26,36–39)
in which the visibility of microcalcifications at
FFDM and DBT were compared have shown
conflicting results. Both Spangler et al (37) and
Poplack et al (36) reported that microcalcifica-
tions are more discernible at FFDM than at DBT.
Kopans et al (38) and Destounis et al (39) showed
that the conspicuity of microcalcifications at DBT
is equivalent or slightly superior to that at FFDM
(26,38,39); however, the authors of these two
studies did not use 2D synthesized mammography
for evaluation of the visibility of microcalcifica-
tions. The high-pass filter used at synthesized
mammography makes microcalcifications appear
more pronounced (Fig 2a) but can also create
pseudocalcifications that can be verified or dis-
proved at DBT (Fig 2b) and/or spot magnification
FFDM (Fig 2c) (12). Studies (31,40,41) have
shown that synthesized mammography with DBT
is noninferior to FFDM alone or combined with
DBT for evaluating microcalcifications. Therefore,
radiologists should use all images at their dis-
posal to search for or exclude microcalcifications.
Thin-section DBT may allow better visualization
of amorphous microcalcifications compared with
synthesized mammography; however, synthesized
mammography allows a global visual assessment
of the whole breast.
RG  •  Volume 39  Number 2 Tirada et al  417

Figure 1.  Amorphous microcalcifications in a 55-year-old woman. (a) Mediolateral spot magnification view shows that the amor-
phous microcalcifications are difficult to see. (b, c) Two-dimensional synthesized mammogram (b) and DBT image (c) acquired with
the use of a high-pass filter show improved visibility of microcalcifications.

Figure 2.  Amorphous microcalcifications in a 43-year-old woman. (a) Two-dimensional synthesized mammogram shows a group
of round and amorphous calcifications in the right breast. (b, c) DBT image (b) and FFDM spot magnification view (c) show two
microcalcifications (oval). These findings are 2D synthesized mammography–related pseudocalcification artifacts..

Artifacts crease with an increasing number of projections,

Artifacts specific to DBT include blurring-ripple
artifacts, truncation artifacts, and artifacts from
loss of skin and superficial tissue resolution. Grid
artifacts and patient motion artifacts seen at
FFDM also can be present at DBT but rarely are
appreciated because of the masking effect of out-
of-plane blurring.
Blurring-Ripple Artifacts
Blurring-ripple artifacts are related to the small
number of projections acquired at DBT, which
limits suppression of anatomic noise from imag-
ing planes outside of the reconstructed section,
analogous to volume averaging, and are seen
perpendicular to the x-ray tube sweep direction
(27,28). In principle, blurring-ripple artifacts de-
disappearing when the number of projections
matches the number of reconstruction sections
(28,42,43). However, as previously discussed, the
number of projections is limited by the trade-off
between the radiation dose and the contrast-to-
noise ratio. These artifacts are less noticeable with
iterative reconstruction than with FBP (44).
When the reconstructed DBT section is in
plane with high-density objects such as biopsy
clips or coarse calcifications, no blurring-ripple
artifacts are seen. Blurring-ripple artifacts are
two-stage phenomena, in which the margins of
these high-density structures initially appear less
well defined and slightly wider than their true
dimensions when visualized on sections imme-
diately out of plane (ie, blurring). This causes
418  March-April 2019 radiographics.rsna.org

Figure 3.  Blurring-ripple artifact

in a 67-year-old woman. Right cra-
niocaudal images obtained in com-
bination DBT (a) and FFDM (b)
mode show a falsely thick skin line
from blurring of the skin in the
DBT image (red arrows in a) and
blurring-ripple artifacts associated
with coarse calcifications (yellow
arrow in a). Both artifacts appear
less prominent with FFDM.

Figure 4.  Blurring-ripple artifact from a metallic biopsy clip in a 52-year-old woman. (a) Synthesized mammogram or C-view me-
diolateral oblique view of the left breast shows a streak artifact along the sweep direction. (b) DBT section 17 of 63 shows a blurring
artifact, with a widening and an indistinct margin. (c) DBT section 40 of 63 shows increased separation of the artifact from blurring
into a ripple or “slinky” artifact.

Figure 5.  Reduction of blurring-

ripple artifact in a 55-year-old
woman (same patient as in Figure
1). Postprocessing metal reduction
software can be applied after im-
age acquisition to reduce blurring-
ripple artifacts. (a) Synthesized
mammogram shows a decrease in
streak artifacts. (b) DBT section 10
of 63 also shows substantial reduc-
tion of blurring-ripple artifacts.

the skin to appear falsely thickened (Fig 3). It
also produces edge blurring and elongation of
biopsy or surgical clips (Fig 4a, 4b). As the dis-
tance of reconstructed sections from the object
increases, the artifacts become more and more
elongated, appearing as a vertical train of ripples
(“slinky” artifact) perpendicular to the sweep
direction, and the ripples are equal in number
to the number of total acquired projections (Fig
4c) (12,28,43). In other words, if there are nine
projections, there are nine out-of-plane ripple
artifacts, and each of these will have one-ninth
of the contrast of the original object in each
reconstructed section, increasing in distance
from one another as the distance from the object
increases (28,45). The artifacts are improved
with metal reduction postprocessing software
(Fig 5) (46,47). Skin markers used to localize ar-
eas of concern and mole markers also can cause
blurring-ripple artifacts, which can be mitigated
RG  •  Volume 39  Number 2 Tirada et al  419
Figure 6.  Dark streak or halo artifacts in a 61-year-old
woman. Magnified synthesized mammogram shows
dark streak or halo artifacts surrounding surgical clips.
The artifacts are the results of photon starvation.
with DBT-specific markers. Blurring-ripple
artifacts also are present at synthesized mam-
mography as streak or halo artifacts surrounding
metallic objects (Fig 6).
Truncation Artifacts
Because of the small (less than 180°) sweep angle
and limited detector size, there is a nonuniform
contribution to the imaging data from breast
tissue located at the periphery of the detec-
tor (Fig 7) (44). Breast tissue captured only by
the peripheral-most acquisitions does not fall
within the reconstructed volume. The x-rays at
the margins of these acquisitions are still inci-
dent on the detector and contribute data to the
reconstruction. This discrepancy results in a
“stair-step” effect, which is a type of truncation
artifact (Fig 8) (44,48). With progressively more
central tube positions, there is an incremental
decrease in the contribution to the total data
from the wide-angle acquisition, resulting in a
step-wise decrease in artifact conspicuity. Stair-
step artifacts seen on individual DBT images are
summated on synthesized mammographic images
to produce a single line (Fig 8). A “bright-edge”
artifact is another form of truncation that results
from overestimation of x-ray attenuation at the
margins of the image. Bright edges at the periph-
ery of reconstructed images result from x-rays
emitted at wide-angle tube positions that must
traverse a greater distance in the breast at mark-
Figure 7.  Simplified diagram of DBT acquisition shows how
truncation artifacts occur. The orange area of the breast is not
included in the wide projection field of view but contributes to
image reconstruction, resulting in a bright-edge artifact. The
red area of the breast is located outside the reconstructed vol-
ume (indicated by the solid black lines between the compres-
sion paddle and the detector) but contributes to attenuation,
resulting in stair-step artifacts.
edly oblique angles before reaching the detector
(Fig 9) (25,33,44). Truncation artifacts can be
minimized with the use of a larger detector size
or with a dynamic detector tilt that is concentric
with the x-ray tube sweep angle.
Loss of Skin and Superficial Tissue
Resolution
Loss of skin and superficial tissue resolution oc-
curs in patients with large or dense breasts. At the
higher radiation doses required, peripheral x-rays
that traverse only skin and subcutaneous tissue at
higher energy levels cause saturation of the detec-
tor, resulting in a burn-out effect (Fig 10) (12).
Motion Artifacts
Motion degrades image quality and dampens the
clarity of microcalcifications. Motion artifacts
can occur because of patient movement, inad-
equate compression, overly long exposure, or
poor positioning technique (49,50). DBT incor-
porates blurring to reduce anatomic noise from
overlapping breast tissue, and additional blurring
from motion artifacts is not visualized readily.
This may further decrease the conspicuity of
microcalcifications. Without concomitant use of
FFDM, degradation of DBT images from mo-
tion blurring may not be apparent. Radiologists
should be vigilant for motion artifacts visible
along the skin line, and the axillary or inframam-
mary folds. Another useful cue is the presence
420  March-April 2019 radiographics.rsna.org

Figure 8.  Stair-step artifact in a 47-year-old woman. (a, b) The shoulder falls outside of the field of view of the re-
constructed volume image but appears as a stair-step artifact on a DBT image (a) and as a bright line on a synthesized
mammogram (arrows) (b). (c) The overlying shoulder can be seen on a cine source image.

of motion-related nonlinear wavy ripple artifacts

(Fig 11). Gross movement also can be seen with
the use of the cine mode.

Additional DBT Artifacts

Other DBT artifacts are processing reconstruc-
tion errors that appear as horizontal lines across all
images; dead pixels on the detector, which cause
black or white dots to appear in the same location
in every exposure; and grid lines, which appear on
FFDM images because of misaligned grids and
on DBT images because of failed power supply
to the array, which prevents grid retraction (51).
These artifacts are relatively rare and usually are
identified or corrected during periodic QC and
calibrations.

DBT QC
DBT is considered a new imaging modality by
the MQSA. Breast imaging facilities are re-
quired to obtain certification in DBT from the
FDA in addition to FFDM accreditation (52).
All personnel including radiologists, technolo-
gists, and medical physicists are mandated to
complete 8 hours of initial DBT training and 15
hours of category 1 continuing medical educa-
tion credits in mammography, with at least 6
hours related to DBT every 3 years to maintain
accreditation (11,52). For medical physicists,
the 15 hours of continuing medical education
should include training related to each mam-
Figure 9.  Bright-edge artifact in a 49-year-
old woman. Bright-edge artifact manifests as
falsely increased attenuation in the axilla.
mographic modality under the physicist’s quality
assurance oversight (11,52).
The ACR and the European Reference Or-
ganization for Quality Assured Breast Screening
and Diagnostic Services (EUREF) have pub-
lished DBT QC protocols. As an alternative, QC
can be performed according to specific manufac-
turer guidelines.
RG  •  Volume 39  Number 2 Tirada et al  421
The purpose of QC is to ensure consistent and
optimal image quality by maintaining standards
for noise, contrast, spatial resolution, and arti-
facts. QC also ensures that DBT radiation doses
adhere to the “as low as reasonably achievable”
(ALARA) principle (30). By conducting periodic
QC and QC testing after major upgrades or re-
pairs such as x-ray tube or detector replacement,
any inadvertent changes in settings or issues with
the performance of the DBT unit can be identi-
Figure 10.  Artifacts in a 63-year-old woman.
(a) Spot compression DBT image of the right
breast shows a jagged appearance of the skin
and loss of detail in the dermal and subcutane-
ous tissues, secondary to saturation of the detec-
tor from a subpectoral dense silicone implant in
the field of view. A stair-step artifact from the
compression paddle and a blur artifact associated
with the biopsy clip are seen. Ripple artifacts are
not seen because metal reduction software was
applied. (b) Synthesized mammogram shows
the same artifacts as on the DBT image (a com-
bination-mode sequence was not performed).
(c) Mediolateral oblique nonimplant-displaced
FFDM view does not show the artifacts.
Figure 11.  Combination DBT/FFDM views of
the right breast show a motion artifact with blur-
ring at FFDM (a) that is not visible on the syn-
thesized mammogram (b). Patient motion was
related to increased examination time for the
double exposure.
fied before problems arise. Because FFDM and
DBT share the same components, such as the
detector and x-ray tube, many DBT QC tests
are similar to those for FFDM and often can
be performed at the same time (53). Therefore,
FFDM QC should not be treated as completely
separate from DBT QC. Problems with detector
and focal spot performance such as those related
to detector nonuniformity, spatial resolution,
signal-to-noise ratio, and contrast-to-noise ratio
422  March-April 2019 radiographics.rsna.org

Table 2: Typical DBT Quality Control

Testing Interval

Manufacturer and Test Technologist Physicist

Hologic Selenia Dimensions test
  ACR phantom image quality Weekly Annually/MEE
  Flat-field test Weekly Annually/MEE
  Artifact evaluation Weekly Annually/MEE
  Automatic exposure control NA Annually/MEE
  Geometry calibration Semiannually NA
  Breast entrance exposure, automatic exposure con- NA Annually/MEE
  trol reproducibility, and average glandular dose
  System resolution NA Annually/MEE
GE SenoClaire and Senographe Pristina test
  ACR phantom image quality Weekly Annually/MEE
  Flat-field test Weekly Annually/MEE
  Artifact evaluation Weekly Annually/MEE
  Automatic optimization of parameters 3D check Monthly Annually/MEE
  Average glandular dose in 3D NA Annually/MEE
  Volume coverage NA Annually/MEE
Siemens Inspiration test
  ACR phantom image quality Daily Annually/MEE
  Flat-field test Weekly Annually/MEE
  Artifact evaluation Weekly Annually/MEE
  Geometric accuracy in x-y and z-resolution NA Annually/MEE
  Average glandular dose in 3D NA Annually/MEE
Fujifilm Aspire Cristalle test
  ACR phantom image quality Daily Annually/MEE
  Flat-field test Weekly Annually/MEE
  Artifact evaluation Weekly Annually/MEE
  Automatic exposure control performance NA Annually/MEE
  Resolution (x-y plane and z-axis) NA Annually/MEE
  Average glandular dose in 3D NA Annually/MEE
  Short-term reproducibility NA Annually/MEE
Note.—Quality control tests vary by manufacturer, and similar tests may be referred to by
different names. MEE = mammography equipment evaluation performed at installation or
after major modifications (ie, component replacement or system upgrade) that may affect the
performance, NA = not applicable.

can affect the overall performance in both DBT
and FFDM modes.
Table 2 gives an overview of common tests
performed by technologists and physicists on
commonly used DBT systems. The recommended
tests, the interval between QC assessments, and
the passing criteria differ for each manufacturer.
A general overview of QC tests that are unique to
DBT is presented, but readers should consult QC
manuals from each DBT system manufacturer for
details specific to their equipment.
Phantom Image Quality Testing
A phantom image quality test is performed
weekly by the technologist and annually by the
medical physicist. There are two ACR mammog-
raphy accreditation phantoms. An older smaller
phantom contains six nylon fibers, five microcal-
cification groups, five masses, and a 4-mm acrylic
disk (as a contrast object for signal-to-noise ratio
and contrast-to-noise ratio consistency tests). A
newer large rectangular phantom (designed for
FFDM and screen-film mammography) contains
six nylon fibers, six microcalcification groups,
and six masses and provides coverage of the
entire field of view of the detector evaluation of
artifacts. To save time, images may be acquired in
a combination FFDM-DBT mode for the weekly
QC. However, the FFDM and DBT modes
may need to be calibrated differently than the
RG  •  Volume 39  Number 2 Tirada et al  423

Figure 13.  Line bar phantom. Spatial resolution test-

Figure 12.  Small ACR mammography accreditation
ing is performed with a line bar phantom placed at 45°
phantom. This phantom is made from acrylic and con-
to the x-ray tube anode-cathode axis, on top of a 4-cm
tains a wax insert to simulate a 4.2-cm compressed
homogeneous acrylic block. There is greater than three
breast with 50% adipose and 50% glandular tissue. The
line pairs per millimeter resolution in this DBT image,
wax insert contains three groups of objects: six nylon fi-
which is a passing score for Hologic Selenia Dimensions.
bers, five microcalcification groups, and five masses em-
bedded at different depths, resulting in different focal
points. DBT sections in which each finding is completely
in focus should be used to evaluate for image quality.
phantom that contains three to 10 line pairs per
millimeter. To perform the test on Hologic and
Siemens DBT units per the manufacturers’ QC
combination mode (as with the Hologic Selenia manuals, the bar phantom is placed on top of a
Dimensions). Hence, a DBT unit that passes the 4-cm homogeneous acrylic block at a 45° angle to
image quality test in combination mode may not the x-ray tube anode-cathode axis (59). In addi-
necessarily pass in the DBT mode or vice versa. tion, the bar phantom must be placed 1 cm from
Therefore, the best practice for weekly image the chest wall and centered laterally, because the
quality tests is to use the modes employed by the size of the effective focal spot varies with the posi-
practice. The medical physicist should test all tion in the imaging plane.
modes at annual intervals. The GE Healthcare DBT system uses an auto-
To score DBT with the phantom, image sec- mated procedure with a proprietary image quality
tions are selected that put each finding in focus. phantom called IQST to measure the modula-
Per the manufacturer’s QC manual, passing tion transfer function, which is a more sensitive
scores may be the same or lower for DBT com- test for detecting changes in spatial resolution.
pared with those for FFDM. For example, when For the FFDM mode, the GE Healthcare system
a small phantom is used, the Siemens Mammo- also uses bar patterns to measure the modulation
mat Inspiration and the Hologic Selenia Dimen- transfer function manually. Again, the perfor-
sions require visualization of at least five fibers, mance criteria are dependent on the manufac-
four specks, and four masses. For the Hologic turer; for example, the resolution guideline for
unit, if the signal-to-noise ratio and high contrast the Hologic Selenia Dimensions system is seven
resolution exceed the manufacturer’s minimal line pairs per millimeter for FFDM and three line
requirement, visualization of four and one-half fi- pairs per millimeter for DBT (59) (Fig 13), while
bers, three specks, and three and one-half masses the GE SenoClaire system uses a parallel and
is acceptable for FFDM, and visualization of four perpendicular modulation transfer function at two
fibers, three specks, and three masses is accept- line pairs per millimeter greater than 49% and
able for DBT (Fig 12). The GE SenoClaire re- four line pairs per millimeter greater than 18% for
quirements are the same score for both DBT and both FFDM and DBT modes.
FFDM, with visualization of at least four fibers,
three specks, and three masses (54–59). Testing for Volume Coverage and
Geometric Accuracy
Evaluation of Spatial Resolution This test is performed to ensure that the entire
Spatial resolution or focal spot performance is imaged object is included in the reconstructed
assessed with a thin high-contrast sheet or bar image, with minimal distortion. The procedure
424  March-April 2019 radiographics.rsna.org

and phantoms used vary according to manu-

facturer. Per the Hologic Selenia Dimensions
QC manual, geometric calibration is checked
semiannually by using automatic validation with
a proprietary geometric phantom containing
embedded beads that should appear in a prede-
termined location on the detector (Fig 14) (59).
Geometric accuracy also can be confirmed while
image quality testing is being performed with the
use of an ACR phantom by recording the consis-
tency of depth along the planes of inserted fibers,
specks, and masses. Per the GE SenoClaire and
GE Senographe Pristina QC manuals, a volume
coverage test is performed to verify that the
object is appropriately reconstructed along the
z-axis. The volume coverage test uses 0.1-mm
aluminum sheets placed above and below a 25-
mm and a 60-mm acrylic plate (57,58). The focal
planes for each aluminum sheet must be within
the reconstructed volume (57,58).

Flat-Field Testing
Figure 14.  Image obtained at 0° projection
The flat-field test is designed to test artifacts with a Hologic Selenia geometry calibration. The
and homogeneity in reconstructed images software automatically evaluates whether the
acquired with a flat-field phantom, which is embedded beads appear in a predetermined lo-
simply an acrylic plate or block. The Hologic cation on the detector.
and Siemens systems require only visual evalu-
ation of the flat-field images for image uni-
formity (Fig 15) (55,59). In addition to the
qualitative visual check, the GE SenoClaire
and GE Senographe Pristina systems provide
quantitative assessment of contrast and signal-
to-noise ratio nonuniformity (55,57–59). Filter
and detector defects are common causes of test
failure (55,57–59).

Conclusion
DBT is a promising modality that has quickly
gained widespread popularity. Radiologists
should understand DBT acquisition parameters,
artifacts, and the steps taken to ensure QC.
Prompt recognition of artifacts and an under-
standing of QC will help to ensure excellence in
imaging quality.
Disclosures of Conflicts of Interest.—N.K. Activities related to the Figure 15.  Image from Hologic Selenia flat-
present article: disclosed no relevant relationships. Activities not field testing performed with a 4-cm radiolucent
related to the present article: expert testimony for Keefe, Keefe, acrylic block without a compression paddle. A
and Unsell. Other activities: disclosed no relevant relationships. homogeneously dark screen indicates acceptable
D.D. Activities related to the present article: disclosed no relevant
uniformity with no artifact.
relationships. Activities not related to the present article: RSNA Re-
search and Education Foundation Research Scholar grant. Other
activities: disclosed no relevant relationships.
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