Different modalities in breast imaging

2. • Breast Cancer - One of the major leading causes of
mortality in women
• Serious Threat World Wide
• Early Diagnosis Helps Better Effective Treatment
• Screening ought to be done in women aged 40 and
above
• So, early diagnostic imaging plays in primary role

3. Imaging Modalities of Breast Tissue
• Screen Film Mammography
• Xeromammography
• Galactography
• Thermomammography
• Digital Mammography
• Ultrasound Breast
• Magnetic Resonance Imaging
• Positron Emission Mammography
• Digital Breast Tomosynthesis

4. Breast Ultrasound
• Characterize an intermediate finding on
mammography
• Evaluate a palpable abnormality
• Increased detection of breast cancer in women with
dense breast tissue and women with high risk
• Specificity of ultrasound greater than mammography
• Operator dependent

5. Breast MRI
• Distinguish between different tissue types
• Soft tissue density
• Higher sensitivity than mammography
• Expensive tool
• Unsuitable for patients with metal implants and
individuals with claustrophobia

6. Mammography
 Key role of Breast Imaging as display of
Microcalcifications
 Usage of screen-film or digital technology
 Better In Conjunction with Breast Ultrasound
 Basic Views: -Craniocaudal (CC)
-Mediolateral Oblique (MLO)
-Mediolateral (ML)
-Lateromedial (LM)

7. Limitations of Mammography
 2D imaging of breast volume
 Superimposed or Overlapping Breast Tissue
 Obscuring of lesions or Microcalcifications
(especially malignancies in an early status)
 Increased number of false-positive and false-
negative results

8.  Poor Sensitivity or Specificity
 Increased recall rates, additional cost and
anxiety
 Patient discomfort due to tight breast
compression

9. To overcome the limitations of Mammography
A new modality with 3D technology for breast volume

10. What is Digital Breast Tomosynthesis?
• a promising digital technology which may be able
to improve diagnostic accuracy in the early
detection of breast cancer
• This system produces a series of images with low
dose tomographic images acquired in an arch
• For visualization of breast in multiple contiguous
slices

11. DBT System
Mammomat Inspiration: Siemens

12. Mammomat Inspiration: Siemens
Digital Tomosynthesis Sytem

13. Hologic: Digital Tomosynthesis System

14. Basic Principle
• Digital Breast Tomosynthesis (DBT) uses small
tomography angle with a limited number of
projection views
• Breast is under compression only for stationary,
not very strong like in mammography
• X-ray source is rotated over a limited arc angle
• a number of low-dose projections are acquired
over a narrow range of angles

15. • Then, reconstructed thin slices of breast tissue
acquisition with the use of filter back projection
method
• the acquired images are processed to give a series of
thin slices through the breast
• 3 dimensional breast images from these slices or
individual layers of the breast
• So, eliminates the tissue overlapping

16. A single projection will not include
any spatial information in the X-ray
direction (z-axis)
Two masses will appear more or
less shifted according to the
position of X-ray source
Basic principle of DBT

18. Difference in image display depending on the different tomographic
angle

19. The Shifting and adding of the 3 images enables the location of the two masses on
the z-axis.
Slices perpendicular to the z-axis can be reconstructed, each with accurate spatial
information.
On the left and right side you see how the images must be shifted to get the
corresponding planes.

20. The back projection of 3 images generates two out-of-plane artifacts as
indicated in the first set of back-projected slices.
25 back projected images result in spread out-of-plane artifacts as shown in the
second set of reconstructed slices.

21. • A series of 1-2 mm slices
• Generally 11-25 projections over 40˚-50˚ tube arc
• Acquisition time 10-25 seconds
• Full field digital mammo detector
• Depends on slice thickness, number of projections
and angular range
• Depends on manufacturer’s specifications

22. • More projections for larger breast
• More projections take better detail but longer scan time
• Scan type – step and shoot or continuous scan
• Increased scan angle is good for better detection of
signals from lesion sized 0.5mm
• Image display and tools for image viewing is same as
other digital systems
• Image storage and transfer in fully digitized system

23. Thin Slices of Breast Volume
Ref: www.medscape.com

24. Ref: vulgaire.com

25. 68-year-old woman, 1.5 cm invasively growing carcinoma, mixed with 2 cm DCIS.
The lesion and its delineation are better visible with tomosynthesis. The fact that
microcalcifications are positioned in the neighbourhood of the tumour suggests a
DCIS component. (With courtesy of KU leuven, Belgium, Prof. van Ongeval and Dr.
van Steeen)

26. 76-year-old-woman, 0.9mm intraductal invasively growing carcinoma, BIRADS 5,
density ACR 2. Tumor evaluation is better with tomosynthesis than with DM.
(With courtesy of MVZ Prof. Dr. Uhlenbrock & Partner, Prof. Dr. Detlev
Uhlenbrock)

27. Better Depth and Contrast Resolution

28. Image Quality with Mass Enhancement

30. FFDM: Full Field Digital Mammogram

33. Benefits of DBT
Reveals the better internal architecture of breast
through thin slices
Visualization of breast tissue in layers
Reduce tissue overlapping and masking effect of
tissue density
Enhance detection of subtle architectural distortion
More detection of obscured cancerous formation

34. Enhance the evaluation and analysis of margins
of mass
Increased invasive cancer detection
More accurate the 3D localization of lesion
Helpful in women with multiple masses and
multiple calcifications clusters on mammogram
Increased sensitivity and specificity for reader
accuracy

35. Contrast Enhanced DBT for abnormal blood flow,
tumor uptake and tumor border delineation
Reduce recall rates
Potential reduction of radiation dose
Avoidance of tight breast compression, so
Reduce patient discomfort

36. Image artifacts
1. Streak artifacts - due to out of plane
- decreased no. of projections
(Larger lesions can cause increased range of artifacts)
Example of the clinical effect of the out-of-plane artifacts caused by a
calcification in a different plane

37. Streak artifacts: the left image with 25 projections shows less streak
artifacts than the right one with only 13 projections.
The lesion can be easier detected in the left image.

38. 2. Over shoot artifacts – if filtering processes extend
beyond the border of sample region in frequency space
3. Some artifacts for missing data
Overshooting artifact: high contrast features such as microcalcifications exhibit
black rims in scan direction

39. Points to think about DBT;
• DBT provides better positive effects for Breast
Screening and Diagnosis.
• But, still need for further researches and results for
approval in some countries
• Radiation doses of DBT examinations
• Significant costs to upgrading existing workstations
for DBT
• Should to be established whether DBT could or should
be used as a standalone imaging modality and whether
one- or two-view DBT would be needed

40. Summary
• Digital Breast Tomosynthesis is advanced
imaging modality
• Gives positive effects ,in general, which are
less in conventional mammograms
• Gives more pronounced results of breast
cancer imaging in digital age
• Greater Potential to increase a woman’s
chances of survival

41. References
• Digital breast tomosynthesis NHSSP Publication
No 69 (2010)
• Fundamentals of Digital Mammography – Andrew
P.Smith, Ph.D
• Theory and Practice of Breast Tomosynthesis -
Andy Smith, Ph.D. Director, Imaging Science
Andrew.smith@hologic.com
• American Society of Breast Disease statement on
Digital Breast Tomosynthesis
• Digital Breast Tomosynthesis ( DBT) Dr. Jun Ni,
Ph.D. & Dr.. Laurie Fajardo Fajardo, M.D.,

42. • Digital Breast Tomosynthesis: A Technological Review -
Matija Males 1, Danijel Mileta 2, Mislav Grgic 1
• Digital Breast Tomosynthesis- Overview of the evidence
and issues for its use in screening for breast cancer
• Executive Summary for FDA Advisory Panel available at:
• http://www.fda.gov/downloads/AdvisoryCommittees/Co
mmitteesMeetingMaterials/MedicalDevices/MedicalDevic
esAdvisoryCommittee/RadiologicalDevicesPanel/UCM22
6757.pdf. Last Accessed March 2, 2011.
• Gir D, Abrams GS, Chough DM et al. Digital breast
tomosynthesis: Observer performance study. AJR Am J
Roentgenol 2009; 193(2):
• Medical Director review 3/2011.

43. • BCBSA Medical Policy Reference Manual [Electronic Version].
6.01.53, 3/10/11
• Specialty Matched Consultant Advisory Panel 6/2012
• BCBSA Medical Policy Reference Manual [Electronic Version].
6.01.53, 7/12/12
• Specialty Matched Consultant Advisory Panel 7/2013
• National Comprehensive Cancer Network (NCCN). Breast Cancer
Screening and Diagnosis. NCCN Guidelines Version 2.2013.
• BCBSA Medical Policy Reference Manual [Electronic Version].
6.01.53, 7/11/13
• Specialty Matched Consultant Advisory Panel 7/2014
• BCBSA Medical Policy Reference Manual [Electronic Version].
6.01.53, 7/10/14

44. • Digital Tomosynthesis: Advanced Breast Cancer
Imaging Technique by Max Wiedmann
• Mammography By Dr. Ruba Khasawneh And Dr.
Arwa Al- kinani
• Mammography and tomosynthesis by Dr Tim
Wood (Clinical Scientist)
• www.siemens.com/inspiration
• www.siemens.com/healthcare
• www.medscape.com
• www.hologic.com
• www.en.wikipedia.org
• www.vulgaire.com
• www.medicaldevice-network.com
• www.thehealthmagazine.com