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Optimization of x-ray spectra in digital mammography through Monte Carlo simulations

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IOP PUBLISHING PHYSICS IN MEDICINE AND BIOLOGY
Phys. Med. Biol. 57 (2012) 1919–1935 doi:10.1088/0031-9155/57/7/1919

Optimization of x-ray spectra in digital

mammography through Monte Carlo simulations

D M Cunha 1 , A Tomal 2 and M E Poletti 2

1 Instituto de Fı́sica, Universidade Federal de Uberlândia, 38400-902 Uberlândia, Minas Gerais,
Brazil
2 Departamento de Fı́sica, FFCLRP, Universidade de São Paulo, 14040-901 Ribeirão Preto,

São Paulo, Brazil

E-mail: dmerigue@infis.ufu.br

Received 3 November 2011, in final form 26 January 2012

Published 16 March 2012
Online at stacks.iop.org/PMB/57/1919

Abstract
In this work, a Monte Carlo code was used to investigate the performance of
different x-ray spectra in digital mammography, through a figure of merit
(FOM), defined as FOM = CNR2 /D̄g , with CNR being the contrast-to-
noise ratio in image and D̄g being the average glandular dose. The FOM
was studied for breasts with different thicknesses t (2 cm  t  8 cm)
and glandular contents (25%, 50% and 75% glandularity). The anode/filter
combinations evaluated were those traditionally employed in mammography
(Mo/Mo, Mo/Rh, Rh/Rh), and a W anode combined with Al or K-edge
filters (Zr, Mo, Rh, Pd, Ag, Cd, Sn), for tube potentials between 22 and
34 kVp. Results show that the W anode combined with K-edge filters provides
higher values of FOM for all breast thicknesses investigated. Nevertheless, the
most suitable filter and tube potential depend on the breast thickness, and for
t  6 cm, they also depend on breast glandularity. Particularly for thick and
dense breasts, a W anode combined with K-edge filters can greatly improve the
digital technique, with the values of FOM up to 200% greater than that obtained
with the anode/filter combinations and tube potentials traditionally employed
in mammography. For breasts with t < 4 cm, a general good performance
was obtained with the W anode combined with 60 μm of the Mo filter at
24–25 kVp, while 60 μm of the Pd filter provided a general good performance
at 24–26 kVp for t = 4 cm, and at 28–30 and 29–31 kVp for t = 6 and 8 cm,
respectively.

1. Introduction

Optimization of the mammographic technique involves improving image quality, while

keeping a low value of the absorbed dose by the glandular breast tissue (Huda et al 2003, Delis
et al 2006). Improvement of image quality is justified by the fact that, although mammography
is the most indicated technique for early detection of breast cancer, its sensitivity is significantly
0031-9155/12/071919+17$33.00 © 2012 Institute of Physics and Engineering in Medicine Printed in the UK & the USA 1919
1920 D M Cunha et al

reduced as the thickness, or density, of the breast increases (Bird et al 1992, Kerlikowske
et al 1996, Kolb et al 2002). On the other hand, reduction of the absorbed dose is necessary due
to the carcinogenic risk associated with the exposure of the glandular breast tissue to ionizing
radiation (Hammerstein et al 1979, NCRP 2004). Among the factors that affect both image
quality and absorbed dose, the x-ray spectrum, characterized by the anode/filter combination
and tube potential, plays a fundamental role (Jennings et al 1981, Thilander-Klang et al 1997).
In digital mammography, the influence of x-ray spectra on image quality and dose to the
breast has been studied using theoretical or experimental methods. Concerning the theoretical
works, Fahrig and Yaffe (1994a, 1994b) developed an analytical model to study spectra
optimization in digital mammography. The authors considered an imaging system based on a
Gd2 O2 S receptor, and showed that, for a W anode, Mo and Rh filters are optimum for breasts of
4 and 6 cm, respectively, while Ag or Cd are optimum for an 8 cm breast. Posteriorly, Fahrig et al
(1996) extended the calculations for an amorphous selenium (a-Se) imaging system, obtaining
similar optimum spectra. Dance et al (2000b) studied, by Monte Carlo (MC) simulations, the
influence of different anode/filter combinations (Mo/Mo, Mo/Rh, Rh/Rh, Rh/Al and W/Rh)
on the average glandular dose, D̄g , for a constant contrast-to-noise ratio (CNR). The authors
considered breasts of different thicknesses and compositions, and a Gd2 O2 S image receptor.
They observed that the Mo/Mo combination is only suitable for a 2 cm breast, while for
thicker breasts, W/Rh and Rh/Al can produce values of CNR equivalent to the Mo/Mo, but
with considerably lower values of D̄g . Flynn et al (2003) simulated an a-Se imaging system,
for various anode/filter combinations (Mo/Mo, W/Mo, W/Al, W/Ag and W/Sn), and the
BR12 breast equivalent material (White et al 1977) with different thicknesses. The authors
compared the performance
 of the different spectra through a figure of merit (FOM), defined as
FOM = CNR/ D̄g , and observed that the W/Sn combination provided higher values of FOM
for breasts thicker than 4 cm. Bernhardt et al (2006) compared by MC simulations and also
experimentally, the performance of the Mo/Mo, Mo/Rh and W/Rh combinations, through a
FOM (CNR2 /D̄g ). The authors showed that the W/Rh combination provides higher values
of the FOM, even for thin breasts. Delis et al (2007) compared the performance of different
anode/filter combinations (Mo/Mo, Mo/Rh, Mo/Nb, Mo/Al, Rh/Rh and W/Al) for a 4 cm
breast. The authors observed that higher values of FOM were provided by a W anode with
a 1.0 mm filtration of Al. Concerning the experimental works, Berns et al (2003) evaluated
the performance of the Mo/Mo, Mo/Rh and Rh/Rh combinations, for a cesium iodide (CsI)
scintillator and amorphous silicon (a-Si) mammographic system, using a 50% adipose-50%
glandular breast equivalent material of different thicknesses, with low-contrast objects within
it. Image quality was based on a contrast-detail score (CD score), which was related to the
visibility of low-contrast objects on the digital image, for a constant value of D̄g . The authors
observed that, for thin breasts, the Mo/Mo combination provided higher CD scores, while for
thicker breasts, better performance was obtained with the Rh/Rh. Samei et al (2005) compared
the FOM (CNR2 /D̄g ) obtained for the Mo/Mo and W/Rh combinations, employing a breast
equivalent material (CIRS, Inc., Norfolk, VA), and a mammographic system with an a-Se
receptor. The authors observed that the W/Rh could provide considerable dose reductions,
especially for thicker and adipose breasts. Young et al (2006) evaluated the CNR and D̄g for
Mo/Mo, Mo/Rh and Rh/Rh combinations using a CsI mammographic system, and polymethyl
methacrylate (PMMA) as a breast equivalent material. Their findings were in agreement with
the work of Berns et al (2003). Toroi et al (2007) investigated the FOM (CNR2 /D̄g ) for a digital
system with an a-Se receptor, and the Mo/Mo, Mo/Rh and W/Rh combinations. The authors
used PMMA as a breast equivalent material, and aluminum sheets to simulate calcifications.
They showed that, for the same value of CNR, the W/Rh provides dose reductions from 12%
Optimization of x-ray spectra in mammography 1921

to 63%, compared to the Mo/Mo combination, for thicknesses between 2 and 7 cm. Similar
conclusions were reported by Williams et al (2008), Engelken et al (2009), Ranger et al (2010)
and Zanca et al (2010), using the same digital mammographic system, but different breast
equivalent materials. Baldelli et al (2010) compared the performance of Mo/Mo, Mo/Rh,
W/Rh and W/Ag combinations for a digital system equipped with an a-Se receptor, using
a breast equivalent material (CIRS, Inc., Norfolk, VA). The authors showed that the W/Rh
provides higher values of FOM for breast thicknesses between 4 and 6 cm.
In summary, results from the literature suggest that a W anode combined with proper
K-edge filtration can be employed for the improvement of image quality, and/or the reduction
of the absorbed dose, in digital mammography, mainly for thicker breasts. Nevertheless, with
respect to the theoretical optimization studies, in general, each author investigated different
anode/filter combinations by employing different geometric models and detector types, thus
making it difficult to directly compare results from different works. Besides, theoretical works
from the literature usually consider no anti-scatter grid (Fahrig and Yaffe 1994b, Fahrig et al
1996, Flynn et al 2003, Delis et al 2007), or a 5:1 linear grid (Dance et al 2000b, Bernhardt
et al 2006). Nevertheless, it was previously shown that the improvement of image quality in
mammography is better accomplished with a cellular grid since, for a constant breast exposure,
it can improve the CNR even for relatively thin breasts (Cunha et al 2010). Experimental
studies, on the other hand, are usually limited by the anode/filter combinations available
in the current mammographic systems. In addition, the influence of breast composition on
determination of optimum spectra was investigated by a few authors (Dance et al 2000b,
Williams et al 2008, Ranger et al 2010). Thus, further investigations about the performance
of different spectra in digital mammography are necessary.
In this work, a MC code for the photon transport simulation was used to study the
performance of different anode/filter combinations and tube potentials (kVp) in digital
mammography. Optimum spectra were determined with respect to the CNR and D̄g , by means
of a FOM, for different breast thicknesses and compositions. The anode/filter combinations
evaluated included those traditionally employed in mammography (Mo/Mo, Mo/Rh and
Rh/Rh) and a W anode combined with Al or K-edge filters (Zr, Mo, Rh, Pd, Ag, Cd and Sn).

2. Methodology

2.1. Simulation of the mammographic examination

The MC code used for the simulation of photon transport in the diagnostic energy range was
described in detail in a previous work (Cunha et al 2010). The code includes interference and
energy broadening effects for the simulation of elastic and inelastic scattering, respectively, and
allows the evaluation of the image quality and dose in screen-film and digital mammography.

2.1.1. Geometric model. The geometric model adopted for the simulation of a
mammographic examination in the cranio-caudal view is shown in figure 1. The 0.3 mm
focal spot is positioned at a distance of 65 cm from the image receptor. The compression
paddle consisted of 3 mm of PMMA. The compressed breast was modeled as a semi-cylinder
of 8 cm of radius and thickness t, which was composed by a homogeneous mixture of adipose
and glandular tissues, enclosed by an external adipose layer of 5 mm thickness (Hammerstein
et al 1979, Dance 1990). Three different breast compositions were evaluated: a 75% adipose-
25% glandular breast, a 50% adipose-50% glandular breast and a 25% adipose-75% glandular
breast. The chest wall was modeled as a semi-infinite block of water (Cunha et al 2010). The
1922 D M Cunha et al

focal spot

object compression paddle

chest
wall t compressed breast
breast support
image receptor anti-scatter grid

Figure 1. Geometric model adopted.

x-ray field was considered restricted to the breast surface, and the photons incident on the
breast were uniformly distributed over it (Dance et al 1992, Cunha et al 2010).
A cylindrical contrasting object with thickness and diameter of 5 mm, composed by
malignant breast tissue, was placed within the breast, simulating a malignant nodule. This size
of nodule is close to the lower limit of detectable malignant lesion size in mammography
(Tomal et al 2010). A cylindrical microcalcification, with thickness and diameter of
200 μm was also simulated. The calcification was composed by calcium hydroxyapatite
of density 3.3 g cm−3 (Dance et al 2000b). The contrasting object was positioned at the center
of mass of the breast. At this position, the contribution of scattered radiation by the breast
to image formation is maximum (Boone et al 2000, Cunha et al 2010) and consequently,
visualization of the lesion becomes more difficult.
The breast support plate consisted of a layer of 1.5 mm of PMMA. The anti-scatter grid
was located under the breast support. Two different grids were investigated: a cellular grid
(grid ratio of 3.8:1), with septa material made from cooper and interspace material composed
by air (Rezentes et al 1999), and a linear grid (grid ratio of 5:1), with septa composed by
lead and interspace composed by PMMA (Dance et al 1992). Superior and inferior grid
covers consisted, each one, of 1 mm of PMMA. The image receptor was located under the
grid. Two different receptors were evaluated: a layer of a-Se, with thickness of 250 μm
(mass thickness dρ = 107 mg cm−2 ), and a CsI layer with thickness of 156 μm
(dρ = 70 mg cm−2 ).

2.1.2. Image receptor modeling. For a given photon of energy E impinging on the receptor
at an angle θ with respect to the perpendicular direction to the receptor surface, the fraction
f (E, cos θ ) of its energy that is deposited in the receptor layer was determined by the analytical
expression (Nielsen and Carlsson 1984):
 
μen dρ
f (E, cos θ ) = 1 − exp − , (1)
ρ cos θ
where μen /ρ and dρ are, respectively, the mass energy absorption coefficient and the mass
thickness of the receptor.
Optimization of x-ray spectra in mammography 1923

Table 1. Anode/filter combinations evaluated. The thickness of each filter is indicated in

parenthesis.
Anode Filter
Mo Mo (30 μm), Rh (25 μm)
Rh Rh (25 μm)
W Al (500 μm), Zr (90 μm), Mo (60 μm), Rh (50 μm),
Pd (50 μm), Ag (50 μm), Cd (50 μm), Sn (50 μm)

2.1.3. Input data. The atomic composition and density of the adipose and glandular breast
tissues were taken from the work of Hammerstein et al (1979), while the values for the
malignant breast tissue were taken from Poletti et al (2002a). For the simulation of elastic
scattering, the structure form factors for the adipose and glandular tissues were taken from
Poletti et al (2002b), and from Poletti et al (2002a) for the malignant tissue. For the simulation
of inelastic scattering, atomic Compton profiles were taken from Biggs et al (1975). Values of
μen /ρ for the Se and CsI were taken from Hubbell and Seltzer (2004).
The polienergetic spectra used in the simulations for the Mo, Rh and W anodes were
computed from the model developed by Boone et al (1997), for different tube potentials,
between 22 and 34 kVp. The anode/filter combinations studied are shown in table 1, and they
were based on combinations proposed for digital mammography (Fahrig and Yaffe 1994b,
Dance et al 2000b, Flynn et al 2003, Baldelli et al 2010), and also in earlier works about
the screen-film technique (Jennings et al 1981, Beaman et al 1983, McDonagh et al 1984,
Desponds et al 1991). Besides, some combinations investigated, namely Mo/Mo, Mo/Rh,
Rh/Rh, W/Al, W/Rh and W/Ag, are commonly used in digital mammographic systems
(Young et al 2006, Williams et al 2008, Baldelli et al 2010). For the W/Zr combination, due to
the low density of the Zr, compared with other K-edge filters, the filter thickness was defined
to match the same mass thickness of the Mo, when this latter is employed with a W anode
(Desponds et al 1991).

2.2. Evaluation of the performance of x-ray spectra

The performance of a given anode/filter combination at different values of kVp was studied
by means of the CNR and average glandular dose. Considering only quantum noise, the CNR
was computed as (Sandborg and Carlsson 1992):
|εPO − εPB |
CNR =  , (2)
σP2O + σP2B + 2σS2B
where εPO and εPB represent the energy deposited in the image receptor by primary photons,
corresponding to the areas behind and beside the object, respectively (Sandborg and Carlsson
1992). The terms σP2O and σP2B represent the variances of εPO and εPB , respectively. The term
σS2B represents the variance in the energy deposited by scattered photons in the area beside the
object, and it was assumed that it was the same in the area behind it (Sandborg and Carlsson
1992).
The average glandular dose, D̄g , was computed by summing the energy deposited in
the glandular tissue by each photon that interacts within the breast, divided by the mass of
glandular breast tissue. The energy deposited in the glandular tissue, for each photon, was
computed as being the energy deposited by the photon in the mixed tissue, weighted by the
relative contribution of the glandular tissue to the corresponding interaction cross section of
the mixed tissue (Dance 1990, Dance et al 2000a, Cunha et al 2010).
1924 D M Cunha et al

Table 2. Values of tube potential (kVp) using the Mo/Mo combination, for the computation of
FOMr , as a function of breast thickness and composition. Adapted from Ranger et al (2010).
Glandularity (%) t = 2 cm t = 4 cm t = 6 cm t = 8 cm
25 26 26 28 30
50 26 26 28 32
75 26 26 30 35

For a given spectrum, the CNR and D̄g were combined through a FOM defined as (Boone
et al 1990):
CNR2
FOM = . (3)
D̄g
Although the value of FOM is independent on the exposure to the breast, the number of
simulated photon stories was defined so that its statistical uncertainty was lesser than 1%.
Following Ranger et al (2010), for comparison between the performance of the different
x-ray spectra investigated, the values of FOM for each breast thickness and composition were
normalized by a reference value FOMr . The value of FOMr corresponds to the FOM obtained
from the conventional mammographic technique, which employs the Mo/Mo anode/filter
combination, with the value of tube potential adjusted as a function of breast thickness and
composition. The values of tube potential for the computation of FOMr were taken from Ranger
et al (2010), and they are shown in table 2. Thus, for a given spectrum, if FOM > FOMr ,
the value (FOM/FOMr )1/2 represents the relative gain in the CNR, compared to the reference
spectrum, for a constant D̄g . Alternatively, the value (FOM/FOMr )−1 represents the dose
reduction factor for a constant CNR (Ranger et al 2010). On the other hand, values of the
FOM for which FOM/FOMr < 1 indicate a spectrum that presents a worse performance,
compared to the conventional technique.
In order to identify optimum energy ranges for each breast thickness, values of FOM were
also computed for monoenergetic beams, between 10 and 34 keV. In this case, for each breast
thickness, the FOM obtained at the energy of 17.44 keV (Kα emission line of the Mo) was
taken as the value of reference, FOMr .

3. Results

This section presents the values of FOM for mono- and polienergetic beams. Unless stated
otherwise, the shown results were obtained for the 5 mm malignant nodule, considering the
cellular grid and the a-Se receptor.

3.1. Monoenergetic beam

Figure 2 shows the FOM as a function of the energy of the incident monoenergetic beam for
a 50% glandular breast of different thicknesses.
Figure 2 shows that, for each breast thickness, there is an energy range for which the
FOM is maximum. For t = 2 cm, the optimum energy values occur between 15 and 16 keV.
For t = 4 cm, optimum values occur between 19–20 keV, and between 21.5–23 keV and
23.5–25.5 keV, for t = 6 cm and 8 cm, respectively. Within each range, the FOM is practically
constant, with variations lesser than 1%. The smooth variation of the FOM, of only a few per
cent, within an energy range of 1–2 keV around an optimum energy value was also observed
by Oliva et al (2009). Similar results of optimum energies were reported by Fahrig and Yaffe
(1994b), Bernhardt et al (2006) and Oliva et al (2009), although small differences occur due
to the different simulated geometries. Compared to the FOM obtained at 17.44 keV, the values
Optimization of x-ray spectra in mammography 1925

Figure 2. Dependence of FOM with beam energy and breast thickness for a 50% glandular breast.

of FOM in the optimum energy range are approximately 8% superior for the 2 cm breast
and 200% higher for the 8 cm breast. These results show that, in digital mammography, the
use of higher energies would be preferable when imaging thicker breasts. Nevertheless, as
pointed out by Fahrig and Yaffe (1994b), the monoenergetic results are useful to provide some
insight into the energetic dependence of the FOM, allowing the identification of optimum
energy ranges, but they do not allow the identification of the optimum spectrum shape for a
polienergetic beam since, in the latter case, the effective energy of the beam changes along the
breast depth.

3.2. Polienergetic beam

3.2.1. Influence of breast thickness and tube potential. Figure 3 shows the values of
FOM/FOMr obtained for different breast thicknesses and anode/filter combinations as a
function of the tube potential for a 50% glandular breast.
Figure 3(a) shows that, for the 2 cm breast, maximum values of FOM are obtained
for the W/Zr and W/Mo combinations at 22 kVp. Nevertheless, different from the
Mo/Mo combination, which presents values practically constant between 22 and 26 kVp, the
performance of the W/Zr decreases quickly with tube potential, with values of FOM/FOMr <
1 for tube potentials greater than 25 kVp. All the other combinations studied showed a worse
performance compared to the reference value, as exemplified in figure 3(a) for the Mo/Rh,
Rh/Rh and W/Rh combinations. For the 4 cm breast, figure 3(b) shows that optimum values
of FOM are obtained with the W/Rh between 22 and 28 kVp, with the maximum value at
26 kVp. The optimal values of FOM within this range indicate that, for this breast thickness, the
W/Rh could improve the CNR by approximately 5%, for the same value of D̄g , or alternatively,
it could reduce the D̄g by 10% for the same CNR in image. The W/Pd combination also shows
good performance within the same kVp range. For the 6 cm breast, figure 3(c) shows that the
W/Pd between 28 and 30 kVp provides a higher value of FOM, followed by the W/Ag at
30 kVp. Figure 3(d) shows that, for the 8 cm breast, the W/Ag combination becomes the
optimum anode/filter combination, with a maximum value of FOM at 30 kVp. Thus, an
improvement in the CNR of 63% would be possible, without increasing the glandular dose,
or, alternatively, a reduction of 62% in the glandular dose, without loss of image quality. Good
1926 D M Cunha et al

(a) (b)

(c) (d)

Figure 3. Dependence of FOM with kVp, for different anode/filter combinations, considering a
50% glandular breast of (a) t = 2 cm, (b) t = 4 cm, (c) t = 6 cm and (d) t = 8 cm.

performance is also achieved with the W/Cd combination at 32 kVp, W/Sn at 34 kVp and
W/Pd at 29 kVp.
Figure 3 shows that, except for the W/Zr combination, a variation of 1–2 kVp from
the optimum tube potential does not significantly impair the performance of the optimum
anode/filter combination. This behavior is similar to that observed for monoenergetic beams.
Nevertheless, for the values of tube potential beyond this optimum kVp range, a significant
reduction of the values of FOM/FOMr is observed. This reduction occurs due to broadening
of the incident spectrum, with the increase of the contribution of photons with non-optimum
energies (Beaman and Lillicrap 1982), and also due to the shape of the transmitted spectrum by
the breast, which tends to be doubly peaked (Jennings et al 1981). Evidently, the performance
of filters with relatively low energy edge values, EK , will be more affected by the increase in
the values of kVp, as observed in figure 3(a) for the W/Zr combination.
Figure 3 shows that, for thin breasts, values of FOM greater than that obtained with the
Mo/Mo combination can be achieved with the W/Zr or W/Mo combinations. Besides, the
Mo/Mo combination is not indicated for breasts thicker than 2 cm since it shows a performance
that becomes even worse as the breast thickness increases, as also observed by Dance et al
(2000b). The Mo/Rh and Rh/Rh combinations did not achieved a good performance for any
breast thickness, compared to results obtained for the W anode with K-edge filters. In particular,
the non-optimum performance of the Rh/Rh was also observed previously by Desponds et al
(1991) and Dance et al (2000b) in screen-film and digital mammography, respectively. These
results indicate that, in digital mammography, a W anode is more adequate for imaging both
thin and thick breasts since the energy spectrum can be adjusted by the use of a suitable K-edge
filter and tube potential.
Optimization of x-ray spectra in mammography 1927

Table 3. Optimum K-edge filters and tube potentials for the W anode, considering a 50% glandular
breast of different thicknesses t. The value EK of the K energy edge of each filter is also indicated.
The values in parenthesis indicate the range of kVp for which the variation of the maximum FOM
is lesser than 1%.
Optimum Optimum tube
t (cm) filter EK (keV) potential (kVp)
2 Zr 18.00 22
4 Rh 23.22 26 (24–28)
6 Pd 24.35 29 (27–30)
8 Ag 25.51 30 (29–31)

The breast thickness is the main factor that affects the performance of a given x-ray spectra
(Fahrig and Yaffe 1994b, Thilander-Klang et al 1997, Dance et al 2000b). For a given breast
thickness, some trends about the most suitable K-edge filter to be employed with the W anode
can be observed by comparing the optimum energies for monoenergetic beams (figure 2) and
the energy edge value EK of the optimum filter, shown in table 3. In general, results show that
the most suitable filter is such that its EK value is slightly higher than the optimum energy.
This correlation is explained by the fact that, for a given breast thickness, the K absorption
edge of the optimum filter reduces significantly the contribution of photons with energies
higher than the optimum monoenergetic values (Beaman and Lillicrap 1982). Nevertheless,
for a given breast thickness, the performance of the optimum K-edge filter is also affected by
the tube potential. The values of optimum tube potentials are also shown in table 3. It can be
observed that the optimum value of kVp is such that the maximum photon energy from the
spectrum is a few keVs (roughly 3–5 keV) above the EK value. This optimum combination of
the K-edge filter and tube potential tends to produce spectra with a considerable amount of
photons whose energies lie within, or close to, the monoenergetic optimum range (Beaman
and Lillicrap 1982).

3.2.2. Influence of lesion type, grid design and image receptor. Simulations performed for the
microcalcification showed that the optimum anode/filter combinations were the same obtained
for a malignant nodule, although the value of the optimum tube potential was generally 1 kVp
higher. These results are in agreement with those reported by Fahrig and Yaffe (1994b) and
Dance et al (2000b), and point to the fact that the identification of optimum spectra is almost
independent of the type of lesion (Fahrig and Yaffe 1994b, Dance et al 2000b, Zanca et al
2010). Simulations performed for the 5:1 linear grid also showed that values of the optimum
tube potential are approximately 1 kVp higher than that obtained with the cellular grid. This
increase occurs due to the lower primary transmission of the linear grid, compared to the
cellular one. Finally, simulations performed for the CsI image receptor showed optimum
anode/filter combinations and tube potentials similar to that obtained for the a-Se.

3.2.3. Influence of breast composition. Simulations performed for the 25% and 75%
glandular breasts showed that, for the 2 cm breast, the optimum anode/filter combination
and tube potential are basically the same indicated in table 3. For t = 4 cm, the W/Rh was the
optimum combination for both 25% and 75% glandular breasts, although it was observed a
slight increase in the optimum tube potential with breast glandularity. For the 25% glandular
breast, maximum values of FOM/FOMr occurred between 24 and 26 kVp, while for the 75%
glandular breast, they occurred at 26–28 kVp. An increase in the ratio FOM/FOMr with
glandularity was also observed. For the 25% glandular breast, the maximum value of the FOM
1928 D M Cunha et al

(a) (b)

Figure 4. Values of FOM/FOMr for the 6 cm breast with (a) 25% and (b) 75% glandular content,
considering a W anode combined with filters of different atomic numbers. The thickness of each
filter is 50 μm.

(a) (b)

Figure 5. Values of FOM/FOMr for the 8 cm breast with (a) 25% and (b) 75% glandular content,
considering a W anode combined with filters of different atomic numbers. The thickness of each
filter is 50 μm.

was approximately 6% greater than the value of FOMr , while for the 75% glandular breast, it
was 16% greater.
For breasts thicker than 4 cm, it was observed that the optimum anode/filter combination
depends on the breast glandularity. Figures 4(a) and (b) show the values of FOM/FOMr for
the 6 cm breast, with 25% and 75% glandular contents, respectively. Values were obtained
with a W anode, and they are shown as a function of the atomic number Z of the filter, for
a given tube potential. For each value of kVp, solid lines were drawn between consecutive
values of Z to help visualization of trends.
Figure 4(a) shows that, for the 25% glandular breast, W/Pd at 28–30 kVp provides higher
values of FOM. This optimum anode/filter combination and tube potentials are the same as
those observed for the 50% glandular tissue. Figure 4(b) shows that, for the 75% glandular
breast, the performance of filters with Z > 46 increases, and the optimum filter becomes Ag
at 30 kVp. Nevertheless, the W/Pd still provides a good performance between 28 and 30 kVp.
Figures 5(a) and (b) show the values of FOM/FOMr for an 8 cm breast, with 25% and
75% glandular content, respectively.
Figure 5(a) shows that, for the 8 cm breast composed of 25% glandular tissue, the
optimum anode/filter combination and tube potential are the same obtained for the 50%
Optimization of x-ray spectra in mammography 1929

glandular breast. On the other hand, for the 75% glandular breast, figure 5(b) shows that the
filters with 48  Z  50 provide a slightly better performance than Ag, with a higher value
of FOM obtained for the W/Sn at 34 kVp. This result, in particular, shows the great benefit
of replacing the Mo/Mo combination with a W anode combined with a proper K-edge filter
when imaging thick and dense breasts since the CNR could be improved by approximately
73%, without dose penalty, or the D̄g could be reduced by 67%, without loss of image quality.
In general, for breasts thicker than 4 cm, results show that, as the breast glandularity
increases, the performance of filters with higher atomic numbers tends to increase, with an
increase in the tube potential. This effect is caused by an increase in the optimum monoenergetic
energy range with breast glandularity. As observed by Dance et al (2000b), an increase in breast
glandularity has a similar effect of a small increase in breast thickness.

3.2.4. Simplified optimum spectra. Results from sections 3.2.1 and 3.2.3 show that, although
optimum results are obtained with a W anode, the most suitable K-edge filter depends on the
breast thickness and composition. For practical purposes, it would be convenient to reduce
the quantity of filters to be employed, by identifying anode/filter combinations that provide a
general good performance over a wide range of breast thicknesses and compositions.
Figures 3(b)–(d), 4 and 5 show that the W/Pd combination could be a good choice
when imaging breasts with 4  t  8 cm, due to its optimum, or nearly optimum,
performance for these breast thicknesses. In fact, its suitability for breasts thicker than
4 cm was observed previously by Jennings et al (1981) and Beaman et al (1983) for screen-film
mammography.
The performance of a given anode/filter combination can be improved by increasing the
filter thickness (Jennings et al 1981, Beaman and Lillicrap 1982, Fahrig and Yaffe 1994b,
Nishino et al 2005) due to the narrowing of the produced spectrum. Simulations performed
with different thicknesses of Pd showed that, by increasing the thickness of this filter, from 50
to 60 μm, the maximum values of FOM/FOMr obtained became equivalent to the optimum
values achieved with other anode/filter combinations, for breasts with 4  t  8 cm with
different glandular contents. This result agrees with those reported by Jennings et al (1981),
who observed that the Pd filter with an intermediate thickness between 51 and 102 μm could
provide good performance for breasts with different thicknesses and compositions.
For breasts thinner than 4 cm, the performance of the W anode combined with 60 μm of
Pd remained inferior to that provided by the W/Zr or W/Mo at 22 kVp, with maximum values
of FOM/FOMr approximately 10% lower than that achieved with the former combination.
Nevertheless, the W/Zr at 22 kVp is optimum only for the 2 cm breast, being inferior to the
W/Mo at 24–25 kVp for a 3 cm breast. Thus, for breast thicknesses t < 4 cm, an overall good
performance is achieved with the W/Mo combination.
In summary, these results indicate that the W/Mo combination could be employed for
breasts with t < 4 cm, while a W anode combined with 60 μm Pd could be employed for breasts
with thicknesses t  4 cm. The optimum values of tube potentials for these combinations are
shown in table 4 for different breast thicknesses. The range of kVp shown in table 4, for each
breast thickness, represents a common range that maximizes the values of FOM/FOMr for
breasts of different glandular contents.

3.2.5. Comparison with the literature. The performance of the different x-ray spectra
investigated in this work was compared with previous results reported in the literature. The
optimum x-ray spectra obtained by different authors are summarized in table 5 for different
thicknesses of breast or breast equivalent material. The optimum spectra obtained in this work
1930 D M Cunha et al

Table 4. Optimum anode/filter combinations and tube potentials for different breast thicknesses
t. The thickness of both Mo and Pd filters is 60 μm. For each breast thickness, the kVp range
represents the range that provides higher values of FOM for different breast compositions.
Optimum Optimum tube
t (cm) anode/filter potential (kVp)

<4 W/Mo 24–25

4 W/Pd 24–26
6 W/Pd 28–30
8 W/Pd 29–31

Table 5. Optimum spectra for digital mammography, for different thicknesses t of breast or
equivalent material, obtained by different authors from the literature. In the second column, the
notation ‘X–Y ’ represents the percentual values X and Y of adipose and glandular breast tissues,
respectively.
t (cm) Composition Optimum spectrum Reference

2 50–50 Mo/Mo at 28 kVp Dance et al (2000b)

W/Moa at 23–25 kVp This work
W/Rh at 24 kVp Bernhardt et al (2006)
CIRS (50–50) W/Rh at 28 kVp Ranger et al (2010)
CIRS (0–100) Mo/Mo at 26 kVp Samei et al (2005)
PMMA W/Rh at 26 kVp Toroi et al (2007)
4 50–50 W/Mo at 24 kVp Fahrig and Yaffe (1994b)
W/Rh at 27 kVp Bernhardt et al (2006)
W/Rh at 28 kVp Dance et al (2000b)
W/Pda at 24–27 kVp This work
BR12 (50–50) Mo/Mo at 24 kVp Flynn et al (2003)
CIRS (50–50) W/Rh at 27 kVpb Williams et al (2008)
W/Rh at 27–28 kVp Baldelli et al (2010)
W/Rh at 29 kVp Ranger et al (2010)
CIRS (0–100) W/Rh at 24 kVp Samei et al (2005)
PMMA W/Rh at 27 kVp Toroi et al (2007) and
Zanca et al (2010)
Water W/Alc at 28–30 kVp Delis et al (2007)
6 50–50 W/Rh at 28 kVp Fahrig and Yaffe (1994b) and
Bernhardt et al (2006)
W/Rh at 30 kVp Dance et al (2000b)
W/Pda at 27–30 kVp This work
BR12 (50–50) W/Sn at 26.5 kVp Flynn et al (2003)
CIRS (50–50) W/Rh at 29 kVp Ranger et al (2010)
CIRS (80–20) W/Rh at 28–30 kVp Baldelli et al (2010)
CIRS (0–100) W/Rh at 24 kVp Samei et al (2005)
PMMA W/Rh at 26 kVp Toroi et al (2007)
8 50–50 Rh/Alc at 30 kVp Dance et al (2000b)
W/Rh at 28 kVp Bernhardt et al (2006)
W/Pda at 28–31 kVp This work
W/Ag (or Cd) at 30–31 kVp Fahrig and Yaffe (1994b)
BR12 (50–50) W/Sn at 31 kVp Flynn et al (2003)
CIRS (50–50) W/Rh at 30 kVp Ranger et al (2010)
CIRS (0–100) W/Rh at 24 kVp Samei et al (2005)
a Considering a filter thickness of 60 μm.
b Result inferred from measurements with CIRS breast equivalent material of 3 and 5 cm, obtained for the
Mammomat Novation DR from Siemens manufacturer.
c Considering a filter thickness of 1 mm.
Optimization of x-ray spectra in mammography 1931

for the W anode combined with 60 μm of Mo or Pd filters, for the 50% glandular breast, were
also included in table 5.
For the 2 cm breast, the comparison between different works from the literature shows
that there is a divergence with respect to the optimum anode/filter combination. Some authors
observed a better performance for the Mo/Mo (Dance et al 2000b, Samei et al 2005), while
the superiority of the W/Rh is reported in others works (Bernhardt et al 2006, Toroi et al 2007,
Ranger et al 2010). Our results agree with the former case, although they also indicate that
neither Mo/Mo nor W/Rh is optimum for a thin breast since other anode/filter combinations,
namely W/Zr or W/Mo, can provide better performance. In particular, the divergences with
the theoretical results of Bernhardt et al (2006) can be attributed to the different geometrical
models adopted in each work. In their work, the authors did not consider the compression
paddle and the adipose shielding layer of the breast. We performed simulations considering a
similar geometrical model, and the results showed that, in this case, the W/Rh provided values
of the FOM slightly greater than the Mo/Mo.
For the 4 cm breast, our results agree that the W/Rh is the optimum anode/filter
combination, as also observed by several authors (Dance et al 2000b, Bernhardt et al 2006,
Toroi et al 2007, Williams et al 2008, Ranger et al 2010, Zanca et al 2010, Baldelli et al 2010).
Good agreement was also observed with the work of Fahrig and Yaffe (1994b) since our
results show that the maximum FOM for the W/Mo was only 1.5% lower than that obtained
with the W/Rh. In particular, compared to the work of Dance et al (2000b), our results show
optimum tube potentials approximately 2 kVp below that reported by the authors, for all
breast thicknesses evaluated. These differences can be attributed to the different conditions
simulated in each work since the authors reported results for a microcalcification, obtained
with a linear anti-scatter grid, while our results were obtained for a malignant nodule, and
considering a cellular grid. For comparison with the work of Delis et al (2007), simulations
were performed considering a W anode and filter of 1 mm of Al. Results showed that the
values of FOM were approximately 2% lower than that obtained for the W/Rh or W/Pd
combinations.
For the 6 cm breast, in agreement with the results observed by different authors (Fahrig
and Yaffe 1994b, Bernhardt et al 2006, Toroi et al 2007, Ranger et al 2010), our results show
that the W/Rh shows good performance at tube potentials between 27 and 29 kVp, although
we observed that the W/Pd provides a FOM approximately 3% higher at 28 kVp. Compared
to the work of Baldelli et al (2010), our results also show that, for the 25% glandular breast, the
W/Rh at 28 kVp is optimum. Our results also agree with the trends observed by the authors,
that the maximum values of the FOM for the W/Ag become closer to that achieved with
the W/Rh as the breast thickness increases, with the former combination providing a better
performance for breasts thicker than 6 cm.
For the 8 cm breast, in agreement with the work of Fahrig and Yaffe (1994b), our results
also show optimum values of the FOM for the W/Ag and W/Cd between 30 and 32 kVp.
Compared with the work of Flynn et al (2003), our results agree that, for the 8 cm breast,
the W/Sn is one of the most suitable anode/filter combinations, with values of the FOM at
32–34 kVp only 3% inferior to the optimum result obtained with the W/Ag at 30 kVp. For
comparison with the result obtained by Dance et al (2000b), simulations were performed for
the Rh/Al combination. Results showed that, in agreement with the authors, this combination
provides values of the FOM greater than the Mo/Mo, Mo/Rh, Rh/Rh or W/Rh, although it
was not superior to the W/Ag combination.
In general, the results obtained in this work show good agreement with the trends observed
in the literature. Small differences are observed with respect to the optimum tube potentials, or
in some cases, a slight deviation of the atomic number of the optimum filter for a given breast
1932 D M Cunha et al

thickness. Some of these divergences are caused by the different geometric conditions defined
in each work, while others could also be due to the input data employed in the simulations
(e.g. breast or equivalent material composition, x-ray spectra). The theoretical approach used
to model the characteristics of the image receptor can also affect the results (Fahrig and
Yaffe 1994b). Nevertheless, as indicated by our results, and also observed by others authors
(Williams et al 2008, Ranger et al 2010), the curves of a FOM tend to be very smooth with
respect to the tube potential, and a variation of 1 or 2 kVp from the optimum value does not
lead to considerable changes in the performance of an anode/filter combination.

4. Conclusions

In this work, the performance of different x-ray spectra in digital mammography was evaluated
through a FOM that relates the squared CNR in image and the average glandular dose D̄g , for
breasts with different thicknesses and compositions. The values of the FOM obtained were
compared with those from the conventional technique, which employs the Mo/Mo anode/filter
combination.
Results for monoenergetic beams show that the optimal energy range increases with breast
thickness, ranging from 15–16 keV for a 2 cm breast to 23.5–25.5 keV, for a 8 cm breast, both
with 50% glandular content. Within these energy ranges, the curves of the FOM are relatively
smooth, with variations lesser than 1%.
For polienergetic spectra, results show that a W anode combined with K-edge filters can
provide values of FOM superior to the combinations traditionally employed in mammography
(Mo/Mo, Mo/Rh, Rh/Rh). Nevertheless, the most suitable K-edge filter depends on the breast
characteristics, mainly on breast thickness. For a given breast thickness, the optimum filter is
such that its energy edge EK is slightly higher than the optimal monoenergetic range. Thus,
for a 50% glandular breast, Zr is optimum for a 2 cm breast, Rh for a 4 cm breast, and Pd and
Ag for 6 and 8 cm breasts, respectively. The optimum tube potential depends on the energy
EK of the filter, with the optimum kVp value such that the maximum photon energy from the
spectrum is roughly 3–5 keV higher than EK . Nevertheless, following the trends observed for
monoenergetic beams, the FOM tends to vary smoothly close to the maximum values, so that
a change of 1–2 kVp from the optimum tube potential leads to small variations (1%) on
the values of FOM/FOMr , excepting for K-edge filters with low atomic numbers, e.g. Zr. For
breasts thicker than 4 cm, the atomic number of the optimum filter and tube potential also
show a slightly increase with breast glandularity.
Compared to the conventional technique, the performance of the W anode combined with
K-edge filters increases with breast thickness and glandularity. For a 2 cm breast, the optimum
FOM, obtained with the W/Zr combination at 22 kVp, was 10% greater than the Mo/Mo at
26 kVp, while for an 8 cm breast, with 75% glandular content, the optimum FOM, provided
by W/Sn at 34 kVp, was approximately 200% greater than the conventional technique. These
results show the great improvements that can be achieved in the digital technique with a W
anode and K-edge filters, especially when imaging thick and dense breasts.
A comparison between the optimum spectra obtained for a malignant nodule and a
microcalcification showed that the optimum anode/filter combination is not influenced by
the type of lesion, although the optimum tube potential was generally 1 kVp higher for the
microcalcification. Similar conclusions were also obtained when optimum spectra obtained
with a cellular and linear anti-scatter grids are compared. Although the optimum anode/filter
combinations were the same for both grids, the optimum tube potential was generally 1 kVp
higher for the linear grid. A comparison between results obtained for the a-Se and CsI receptors
showed that optimum spectra were basically the same for both receptors.
Optimization of x-ray spectra in mammography 1933

The W/Pd provides an overall good performance for breasts with t  4 cm, due to its
optimal, or nearly optimal, values of FOM/FOMr . By increasing the Pd thickness, from 50
to 60 μm, the values of FOM/FOMr became equivalent to the optimum values obtained with
other combinations for breasts with t  4 cm and different glandular contents. Nevertheless,
its performance was inferior to that achieved with the W/Mo combination for relatively thin
breasts (t < 4 cm). These results suggest that, for t < 4 cm, the W/Mo combination should
be employed, while the W anode combined with 60 μm of the Pd filter could be employed for
breasts with t  4 cm.
The results obtained in this work show good agreement with the trends observed,
theoretically or experimentally, by other authors, although divergences are observed with
respect to the optimum tube potential, or in some cases, with respect to the atomic number of
the optimum filter. These divergences can be attributed to the different conditions simulated,
or experimentally employed, in each work, such as the breast model and composition, grid
design, or x-ray spectra.
Finally, it should be mentioned that, in this work, we adopted the breast model proposed
by Hammerstein et al (1979), so that our results could be more comparable to theoretical and
experimental results from the literature. Nevertheless, the development of the technique of
dedicated breast computed tomography (Boone et al 2001) has provided detailed information
about the structure and composition of the breast. In particular, the work of Huang et al (2008)
showed that the breast external layer is composed by 1.5 mm of skin, while the work of Yaffe
et al (2009) showed that the average glandular content in the breast is approximately 20%.
Thus, further optimization studies should be performed, in order to include a more realistic
model of the breast and evaluate its influence on optimum x-ray spectra.

Acknowledgments

The authors would like to acknowledge the Brazilian agencies Fundação de Amparo à Pesquisa
do Estado de Minas Gerais, Fundação de Amparo à Pesquisa do Estado de São Paulo, and to
the Pró-Reitoria de Pós-Graduação e Pesquisa of the Universidade Federal de Uberlândia.

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