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INTRODUCTION: The purpose of our study was to compare the performance of 2D (FFDM) against 3D (FFDM plus DBT) examinations in the post-treatment surveillance of asymptomatic breast cancer survivors. METHODS: A list of women with a history of breast cancer who underwent screening mammography (2D or 3D) from 5/2017 to 5/2020 was retrieved. A total of 20,210 examinations were identified and performance metrics were compared. RESULTS: There were no statistically significant difference in cancer detection rate (CDR) (p = 0.38), recall rate (RR) (p = 0.087), or positive predictive value (PPV) (p = 0.74) between 2D vs. 3D examinations. Stratification by breast tissue identified no statistically significant difference in CDR (p = 0.581 and p = 0.428), RR (p = 0.230 and p = 0.205), or PPV (p = 0.908 and p = 0.721) between fatty/scattered and heterogeneous/extremely dense breast tissue when comparing 2D vs 3D examinations. Stratification by age did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 2D vs. 3D examinations in the 60-69 years group (p = 0.021). Stratification by race did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased with 3D vs. 2D examinations in white women (p = 0.036). Stratification by laterality (bilateral vs. unilateral post mastectomy) did not identify a significant difference in RR or PPV between the two groups. CDR was statistically increased in 2D vs. 3D examinations in unilateral studies (p = 0.009). CONCLUSION: For asymptomatic women with a history of breast cancer, there is no evidence that the addition of DBT to FFDM improves CDR, RR, or PPV. IMPLICATIONS FOR PRACTICE: More studies are needed concerning screening methodologies supplementing FFDM in the screening regimens of breast cancer survivors.

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Digital breast tomosynthesis (DBT) is a fairly recent breast imaging technique invented to overcome the challenges of overlapping breast tissue. Ultrasonography (USG) was used as a complementary tool to DBT for the purpose of this study. Nonetheless, breast magnetic resonance imaging (MRI) remains the most sensitive tool to detect breast lesion. The purpose of this study was to evaluate diagnostic performance of DBT, with and without USG, versus breast MRI in correlation to histopathological examination (HPE). This was a retrospective study in a university hospital over a duration of 24 months. Findings were acquired from a formal report and were correlated with HPE. The sensitivity of DBT with or without USG was lower than MRI. However, the accuracy, specificity and PPV were raised with the aid of USG to equivalent or better than MRI. These three modalities showed statistically significant in correlation with HPE (p < 0.005, chi-squared). Generally, DBT alone has lower sensitivity as compared to MRI. However, it is reassuring that DBT + USG could significantly improve diagnostic performance to that comparable to MRI. In conclusion, results of this study are vital to centers which do not have MRI, as complementary ultrasound can accentuate diagnostic performance of DBT.

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Digital breast tomosynthesis (DBT) is gradually being implemented in routine clinical breast imaging practice. The technique of image acquisition reduces the confounding effect of overlapping breast tissue, which substantially affects cancer detection, abnormal recall, and interval cancer rates in a screening/ surveillance setting. In a diagnostic setting, tomosynthesis also allows for improved lesion localization and characterization over conventional imaging, which potentially improves the accuracy and improved workflow efficiency. To optimize the utility of tomosynthesis, imagers should be aware of the pertinent aspects of image acquisition as it relates to interpretation, the appearance of benign and malignant pathologies, and sources of possible misinterpretation. This article aims to provide a practical knowledge base of DBT and demonstrate its potential benefits when incorporated into routine clinical practice.

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OBJECTIVES: To evaluate the diagnostic performance in the assessment setting of three protocols: one-view wide-angle digital breast tomosynthesis (WA-DBT) with synthetic mammography (SM), two-view WA-DBT/SM, and two-view digital mammography (DM). METHODS: Included in this retrospective study were patients who underwent bilateral two-view DM and WA-DBT. SM were reconstructed from the WA-DBT data. The standard of reference was histology and/or 2 years follow-up. Included were 205 women with 179 lesions (89 malignant, 90 benign). Four blinded readers randomly evaluated images to assess density, lesion type, and level of suspicion according to BI-RADS. Three protocols were evaluated: two-view DM, one-view (mediolateral oblique) WA-DBT/SM, and two-view WA-DBT/SM. Detection rate, sensitivity, specificity, and accuracy were calculated and compared using multivariate analysis. Reading time was assessed. RESULTS: The detection rate was higher with two-view WA-DBT/SM (p = 0.063). Sensitivity was higher for two-view WA-DBT/SM compared to two-view DM (p = 0.001) and one-view WA-DBT/SM (p = 0.058). No significant differences in specificity were found. Accuracy was higher with both one-view WA-DBT/SM and two-view WA-DBT/SM compared to DM (p = 0.003 and > 0.001, respectively). Accuracy did not differ between one- and two-view WA-DBT/SM. Two-view WA-DBT/SM performed better for masses and asymmetries. Reading times were significantly longer when WA-DBT was evaluated. CONCLUSIONS: One-view and two-view WA-DBT/SM can achieve a higher diagnostic performance compared to two-view DM. The detection rate and sensitivity were highest with two-view WA-DBT/SM. Two-view WA-DBT/SM appears to be the most appropriate tool for the assessment of breast lesions. KEY POINTS: • Detection rate with two-view wide-angle digital breast tomosynthesis (WA-DBT) is significantly higher than with two-view digital mammography in the assessment setting. • Diagnostic accuracy of one-view and two-view WA-DBT with synthetic mammography (SM) in the assessment setting is higher than that of two-view digital mammography. • Compared to one-view WA-DBT with SM, two-view WA-DBT with SM seems to be the most appropriate tool for the assessment of breast lesions.

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Breast cancer is a common cancer in women. Early detection of breast cancer in particular and cancer, in general, can considerably increase the survival rate of women, and it can be much more effective. This paper mainly focuses on the transfer learning process to detect breast cancer. Modified VGG (MVGG) is proposed and implemented on datasets of 2D and 3D images of mammograms. Experimental results showed that the proposed hybrid transfer learning model (a fusion of MVGG and ImageNet) provides an accuracy of 94.3%. On the other hand, only the proposed MVGG architecture provides an accuracy of 89.8%. So, it is precisely stated that the proposed hybrid pre-trained network outperforms other compared Convolutional Neural Networks. The proposed architecture can be considered as an effective tool for radiologists to decrease the false negative and false positive rates. Therefore, the efficiency of mammography analysis will be improved.

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OBJECTIVE: To determine whether there is added benefit for 3D mammography in the context of screening and diagnostic imaging, particularly relating to known prognostic characteristics, including histopathology, receptor status, and axillary lymph node involvement. METHODS: An institutional review board-approved retrospective review was performed of our mammography and pathology databases from October 2012 to May 2015 to identify biopsy-proven invasive breast carcinoma detected on screening and diagnostic mammograms by 2D plus 3D (2D + 3D) imaging. Percentages of cancer detection by 2D and 3D were compared. Correlation with histopathology and lymph node status was analyzed. RESULTS: Of 53 cancers diagnosed on 12 543 screening mammograms, 36 (67.9%) were better visualized on 3D (not visualized, equivocal, or only seen in retrospect on 2D). Of the 62 cancers diagnosed on 4090 diagnostic mammograms, 24 (38.7%) cancers were better detected on 3D. A statistically significant greater number of cancers were better detected on 3D in the screening compared to the diagnostic mammograms (67.9% vs 38.7%, P < .05). A significantly higher frequency of less aggressive tumors (grade I and grade II, positive estrogen/progesterone receptor, Her2 negative) was detected by 3D, with higher significance in the screening population. Additionally, there was a higher frequency of positive axillary lymph nodes in cancers detected by 3D in the screening group. CONCLUSION: Three-dimension increases invasive breast cancer detection, particularly pathologically less aggressive tumors, in both screening and diagnostic mammograms with more benefit for the screening population. Three-dimensional mammography detected more breast cancer associated with metastatic axillary lymph nodes in the screening population.

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BACKGROUND: The purpose of this study is to confirm the position of DBT in breast cancer screening in Japan, to assess cancer detection rates, recall rates, positive predictive value (PPV), and to evaluate the type of mammographic findings of cancer with the use of digital mammography alone (2DDM) and combined with digital breast tomosynthesis (DBT). METHODS: 11,894 examinations of the opportunistic breast cancer screening using only 2DDM and 2DDM plus DBT were performed from May 1, 2017 to March 31, 2019. The 11,894 women [3535 women who received DBT in addition to 2DDM (3D group) and 8359 who received 2DDM only (2D group)] participated in this study. The study was approved by the Institute's Ethics Committee and all participants provided written informed consent. RESULTS: The recall rate was 2.6% for the 3D group and 3.6% for the 2D group (p < 0.01). The cancer detection rate was 0.17% in both 3D and 2D groups (p = 0.978). The positive predictive value (PPV) was 6.5% for the 3D group and 4.7% for the 2D group (p = 0.484). The cause of the decrease in recall rate was due to a decrease in the finding of focal asymmetric density (FAD). CONCLUSION: The recall rate was improved by using DBT for breast cancer screening in Japanese women. Cancer detection rates were exactly the same in DBT and 2DDM groups, so only DBT non-inferiority could be verified. We have verified that breast cancer screening combined with DBT is useful even for Japanese women to reduce unnecessary further examination.

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BACKGROUND: Digital breast tomosynthesis (DBT) is a mammographic technique which improves the detection of breast cancer. Architectural distortion of malignancy may be occult on 2D mammography and ultrasound but detected by DBT. METHODS: 110 patients who underwent 116 DBT-guided needle biopsies for architectural distortion were identified between June 2014 and August 2017 and underwent review of medical records. RESULTS: 59 of 116 biopsies (51%) revealed lesions warranting further consideration or excision. These included 21 specimens with invasive carcinoma, 2 ductal carcinoma in situ (DCIS), 5 atypical ductal hyperplasia, 4 atypical lobular hyperplasia, and 2 other lesions. 46 lesions were excised. Surgical pathology demonstrated 22 malignant lesions (20 invasive carcinomas and 2 DCIS). 11 patients continued surveillance and two patients were lost to follow up. 94 lesions (87%) were not visible on ultrasonography. CONCLUSIONS: DBT-guided biopsy for architectural distortion detected a malignancy in 19% of lesions, demonstrating the importance of pathologic diagnosis for lesions without correlating ultrasound findings.

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Objective: To compare digital breast tomosynthesis (DBT) and conventional full-field digital mammography (FFDM) in the detectability of breast cancers in patients with dense breast tissue, and to determine the influencing factors in the detection of breast cancers using the two techniques. Materials and Methods: Three blinded radiologists independently graded cancer detectability of 300 breast cancers (288 women with dense breasts) on DBT and conventional FFDM images, retrospectively. Hormone status, histologic grade, T stage, and breast cancer subtype were recorded to identify factors affecting cancer detectability. The Wilcoxon signed-rank test was used to compare cancer detectability by DBT and conventional FFDM. Fisher's exact tests were used to determine differences in cancer characteristics between detectability groups. Kruskal-Wallis tests were used to determine whether the detectability score differed according to cancer characteristics. Results: Forty breast cancers (13.3%) were detectable only with DBT; 191 (63.7%) breast cancers were detected with both FFDM and DBT, and 69 (23%) were not detected with either. Cancer detectability scores were significantly higher for DBT than for conventional FFDM (median score, 6; range, 0-6; p < 0.001). The DBT-only cancer group had more invasive lobular-type breast cancers (22.5%) than the other two groups (i.e., cancer detected on both types of image [both-detected group], 5.2%; cancer not detected on either type of image [both-non-detected group], 7.3%), and less detectability of ductal carcinoma in situ (5% vs. 16.8% [both-detected group] vs. 27.5% [both-non-detected group]). Low-grade cancers were more often detected in the DBT-only group than in the both-detected group (22.5% vs. 10%, p = 0.026). Human epidermal growth factor receptor-2 (HER-2)-negative cancers were more often detected in the DBT-only group than in the both-detected group (92.3% vs. 70.5%, p = 0.004). Cancers surrounded by mostly glandular tissue were detected less often in the DBT only group than in the both-non-detected group (10% vs. 31.9%, p = 0.016). DBT cancer detectability scores were significantly associated with cancer type (p = 0.012), histologic grade (p = 0.013), T and N stage (p = 0.001, p = 0.024), proportion of glandular tissue surrounding lesions (p = 0.013), and lesion type (p < 0.001). Conclusion: Invasive lobular, low-grade, or HER-2-negative cancer is more detectable with DBT than with conventional FFDM in patients with dense breasts, but cancers surrounded by mostly glandular tissue might be missed with both techniques.

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RATIONALE AND OBJECTIVES: A linear array of carbon nanotube-enabled x-ray sources allows for stationary digital breast tomosynthesis (sDBT), during which projection views are collected without the need to move the x-ray tube. This work presents our initial clinical experience with a first-generation sDBT device. MATERIALS AND METHODS: Following informed consent, women with a "suspicious abnormality" (Breast Imaging Reporting and Data System 4), discovered by digital mammography and awaiting biopsy, were also imaged by the first generation sDBT. Four radiologists participated in this paired-image study, completing questionnaires while interpreting the mammograms and sDBT image stacks. Areas under the receiver operating characteristic curve were used to measure reader performance (likelihood of correctly identifying malignancy based on pathology as ground truth), while a multivariate analysis assessed preference, as readers compared one modality to the next when interpreting diagnostically important image features. RESULTS: Findings from 43 women were available for analysis, in whom 12 cases of malignancy were identified by pathology. The mean areas under the receiver operating characteristic curve was significantly higher (p < 0.05) for sDBT than mammography for all breast density categories and breast thicknesses. Additionally, readers preferred sDBT over mammography when evaluating mass margins and shape, architectural distortion, and asymmetry, but preferred mammography when characterizing microcalcifications. CONCLUSION: Readers preferred sDBT over mammography when interpreting soft-tissue breast features and were diagnostically more accurate using images generated by sDBT in a Breast Imaging Reporting and Data System 4 population. However, the findings also demonstrated the need to improve microcalcification conspicuity, which is guiding both technological and image-processing design changes in future sDBT devices.

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PURPOSE: To assess the visibility of microcalcifications in images generated by a first-generation carbon-nanotube (CNT)-enabled stationary digital breast tomosynthesis (sDBT) device, using magnified 2D mammography and conventional, moving-source DBT as references for comparison. METHODS: Lumpectomy specimens were imaged by magnified mammography and two 3D mammography approaches, including sDBT and moving-source DBT. The planar size of individual microcalcifications was measured in the reconstructed image stacks of sDBT and moving-source DBT and compared to the magnified mammography image. An artifact spread function (ASF) was used to assess the depth dimensions of the microcalcifications displayed through the reconstructed image stacks. Breast-imaging specialists rated their preference for one imaging modality over another when interpreting microcalcifications in the magnified mammography image and synthetic slab images from sDBT and moving-source DBT. RESULTS: The planar size of individual microcalcifications was similar in images generated by sDBT and moving-source DBT when the sDBT projections were binned to match the pixel size used by the moving-source DBT system. However, the unique structure of sDBT allowed for a wider-angle span of projection views and operation of the detector in full-resolution mode without significantly compromising the scan time. In this configuration, the planar sizes of individual microcalcifications displayed by sDBT was more similar to magnified mammography than moving-source DBT, and the microcalcifications had a narrower ASF through depth. Readers preferred sDBT over moving-source DBT when assessing microcalcifications in synthetic slab images, although magnified mammography was rated highest overall. CONCLUSIONS: The sDBT system displayed microcalcifications as well as conventional, moving-source DBT when the effective pixel size of the detector was matched. However, with the detector in its full-resolution mode, sDBT displayed microcalcifications with greater clarity. Readers still preferred images generated by magnified mammography over both 3D mammography approaches. This finding is guiding continued hardware and software development to optimize the sDBT technology.

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OBJECTIVE: To compare digital breast tomosynthesis (DBT) and conventional full-field digital mammography (FFDM) in the detectability of breast cancers in patients with dense breast tissue, and to determine the influencing factors in the detection of breast cancers using the two techniques. MATERIALS AND METHODS: Three blinded radiologists independently graded cancer detectability of 300 breast cancers (288 women with dense breasts) on DBT and conventional FFDM images, retrospectively. Hormone status, histologic grade, T stage, and breast cancer subtype were recorded to identify factors affecting cancer detectability. The Wilcoxon signed-rank test was used to compare cancer detectability by DBT and conventional FFDM. Fisher's exact tests were used to determine differences in cancer characteristics between detectability groups. Kruskal-Wallis tests were used to determine whether the detectability score differed according to cancer characteristics. RESULTS: Forty breast cancers (13.3%) were detectable only with DBT; 191 (63.7%) breast cancers were detected with both FFDM and DBT, and 69 (23%) were not detected with either. Cancer detectability scores were significantly higher for DBT than for conventional FFDM (median score, 6; range, 0–6; p < 0.001). The DBT-only cancer group had more invasive lobular-type breast cancers (22.5%) than the other two groups (i.e., cancer detected on both types of image [both-detected group], 5.2%; cancer not detected on either type of image [both-non-detected group], 7.3%), and less detectability of ductal carcinoma in situ (5% vs. 16.8% [both-detected group] vs. 27.5% [both-non-detected group]). Low-grade cancers were more often detected in the DBT-only group than in the both-detected group (22.5% vs. 10%, p = 0.026). Human epidermal growth factor receptor-2 (HER-2)-negative cancers were more often detected in the DBT-only group than in the both-detected group (92.3% vs. 70.5%, p = 0.004). Cancers surrounded by mostly glandular tissue were detected less often in the DBT only group than in the both-non-detected group (10% vs. 31.9%, p = 0.016). DBT cancer detectability scores were significantly associated with cancer type (p = 0.012), histologic grade (p = 0.013), T and N stage (p = 0.001, p = 0.024), proportion of glandular tissue surrounding lesions (p = 0.013), and lesion type (p < 0.001). CONCLUSION: Invasive lobular, low-grade, or HER-2-negative cancer is more detectable with DBT than with conventional FFDM in patients with dense breasts, but cancers surrounded by mostly glandular tissue might be missed with both techniques.

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PURPOSE: To compare the efficacy of use of digital breast tomosynthesis (DBT) with standard digital mammography (DM) workup views in the breast cancer assessment clinic. MATERIALS AND METHODS: The Tomosynthesis Assessment Clinic trial (TACT), conducted between 16 October 2014 and 19 April 2016, is an ethics-approved, monocenter, multireader, multicase split-plot reading study. After written informed consent was obtained, 144 females (age > 40 years) who were recalled to the assessment clinic were recruited into TACT. These cases (48 cancers) were randomly allocated for blinded review of (1) DM workup and (2) DBT, both in conjunction with previous DM from the screening examination. Fifteen radiologists of varying experience levels in the Australia BreastScreen Program were included in this study, wherein each radiologist read 48 cases (16 cancers) in 3 non-overlapping blocks. Diagnostic accuracy was measured by means of sensitivity, specificity, and positive (PPV) and negative predictive values (NPV). The receiver-operating characteristic area under the curve (AUC) was calculated to determine radiologists' performances. RESULTS: Use of DBT (AUC = 0.927) led to improved performance of the radiologists (z = 2.62, p = 0.008) compared with mammography workup (AUC = 0.872). Similarly, the sensitivity, specificity, PPV, and NPV of DBT (0.93, 0.75, 0.64, 0.96) were higher than those of the workup (0.90, 0.56, 0.49, 0.92). Most radiologists (80%) performed better with DBT than standard workup. Cancerous lesions on DBT appeared more severe (U = 33,172, p = 0.02) and conspicuous (U = 24,207, p = 0.02). There was a significant reduction in the need for additional views (χ2 = 17.63, p < 0.001) and recommendations for ultrasound (χ2 = 8.56, p = 0.003) with DBT. CONCLUSIONS: DBT has the potential to increase diagnostic accuracy and simplify the assessment process in the breast cancer assessment clinic. KEY POINTS: • Use of DBT in the assessment clinic results in increased diagnostic accuracy. • Use of DBT in the assessment clinic improves performance of radiologists and also increases the confidence in their decisions. • DBT may reduce the need for additional views, ultrasound imaging, and biopsy.

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This pictorial essay demonstrates the variable appearances of ductal carcinoma in situ on full-field digital mammography, synthesized mammography, and digital breast tomosynthesis. The spectrum of intercase and intracase variability suggests further refinement of reconstruction algorithms for synthesized mammography may be necessary to maximize early detection of ductal carcinoma in situ.

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PURPOSE: To determine which modalities [2D mammography (2D), digital breast tomosynthesis (DBT), whole breast sonography (WBS)] are optimal for screening depending on breast density. METHODS: Institutional retrospective cohort study of 2013 screening mammograms (16,789), sorted by modalities and density. RESULTS: Cancer detection is increased by adding WBS to 2D (P=.02) for the overall study population. Recall rate was lowest with 2D+DBT (10.2%, P<.001) and highest with 2D+DBT+WBS (23.6%, P<.001) for the overall study population as well. CONCLUSION: Women with dense and nondense breasts benefit from reduced recall rate with the addition of DBT; however, this benefit is negated with the addition of WBS.

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Breast tomosynthesis, a three-dimensional x-ray based breast imaging technology, has been available for clinical use in the United States since 2011. In this paper we review the literature on breast cancer screening with this new technology including where gaps in knowledge remain.

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OBJECTIVE: The objective of our study was to assess the clinical performance of combined 2D-3D digital breast tomosynthesis (DBT), referred to as "3D DBT," compared with 2D digital mammography (DM) alone for screening mammography in a community-based radiology practice. MATERIALS AND METHODS: Performance outcomes measures were assessed for 14 radiologists who interpreted more than 500 screening mammography 3D DBT studies after the initiation of tomosynthesis. Outcomes from screening mammography during the study period between August 9, 2011, and November 30, 2012, using 3D DBT (n = 23,149 patients) versus 2D DM (n = 54,684 patients) were compared. RESULTS: For patients screened with 3D DBT, the relative change in recall rate was 16.1% lower than for patients screened with 2D DM (p > 0.0001). The overall cancer detection rate (CDR), expressed as number of cancers per 1000 patients screened, was 28.6% greater (p = 0.035) for 3D DBT (6.3/1000) compared with 2D DM (4.9/1000). The CDR for invasive cancers with 3D DBT (4.6/1000) was 43.8% higher (p = 0.0056) than with 2D DM (3.2/1000). The positive predictive value for recalls from screening (PPV1) was 53.3% greater (p = 0.0003) for 3D DBT (4.6%) compared with 2D DM (3.0%). No significant difference in the positive predictive value for biopsy (PPV3) was found for 3D DBT versus 2D DM (22.8% and 23.8%, respectively) (p = 0.696). CONCLUSION: In community-based radiology practice, mammography screening with 3D DBT yielded lower recall rates, an increased CDR for cancer overall, and an increased CDR for invasive cancer compared with 2D DM. The PPV1 was significantly greater in the group screened using 3D DBT.

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