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Digital Breast Tomosynthesis in
the Diagnostic Setting: Indications
and Clinical Applications1
Heather R. Peppard, MD
Brandi E. Nicholson, MD
Carrie M. Rochman, MD
Judith K. Merchant, MD
Ray C. Mayo III, MD
Jennifer A. Harvey, MD
Abbreviations: BI-RADS = Breast Imaging
Reporting and Data System, DBT = digital
breast tomosynthesis, FDA = Food and Drug
Administration, FFDM = full-field digital mam-
mography, MLO = mediolateral oblique, 3D =
three-dimensional, 2D = two-dimensional
RadioGraphics 2015; 35:0000–0000
Published online 10.1148/rg.2015140204
Content Codes:
1
From the Department of Medical Imaging and
Radiology, University of Virginia Health System,
1 Hospital Dr, PO Box 800170, Charlottesville,
VA 22908 (H.R.P., B.E.N., C.M.R., R.C.M.,
J.A.H.); and Department of Breast Imaging,
Women’s Diagnostic Center, Louisville, Ky
(J.K.M.). Presented as an education exhibit at
the 2013 RSNA Annual Meeting. Received April
30, 2014; revision requested August 21 and re-
ceived September 18; accepted September 23.
For this journal-based SA-CME activity, H.R.P.,
J.K.M., and J.A.H. have provided disclosures
(see p 0000); all other authors, the editor, and
the reviewers have disclosed no relevant relation-
ships. Address correspondence to H.R.P. (e-
mail: hp4h@virginia.edu).
SA-CME LEARNING OBJECTIVES
After completing this journal-based SA-CME
activity, participants will be able to:
■■Discuss the clinical advantages and
disadvantages of DBT in the diagnostic
setting.
■■Recognizesubtle differences in the
imaging appearances of breast cancer at
DBT compared with traditional diagnos-
tic mammography.
■■Describe the use of DBT to localize
lesions and determine extent of disease
in women with suspected or newly diag-
nosed breast cancer.
See www.rsna.org/education/search/RG.
BREAST IMAGING
1
Digital breast tomosynthesis (DBT) is an emerging technology
used in diagnostic breast imaging to evaluate potential abnormali-
ties. In DBT, the compressed breast tissue is imaged in a quasi–
three-dimensional manner by performing a series of low-dose
radiographic exposures and using the resultant projection image
dataset to reconstruct cross-sectional in-plane images in standard
mammographic views. Improved visualization of breast detail at di-
agnostic DBT allows improved characterization of findings, includ-
ing normal structures and breast cancer. This technology reduces
the summation of overlapping breast tissue, which can mimic breast
cancer, and provides improved detail of noncalcified mammograph-
ic findings seen in breast cancer. It also assists in lesion localization
and determining mammographic extent of disease in women with
known or suspected breast cancer. The authors review the potential
uses, benefits, and limitations of DBT in the diagnostic setting and
discuss how radiologists can best use DBT to characterize lesions,
localize potential abnormalities, and evaluate the extent of known
or suspected breast cancer. The authors’ experience shows that
DBT can be implemented effectively in the diagnostic workflow to
evaluate and localize potential lesions more efficiently. DBT may
potentially replace conventional supplemental mammography at
diagnostic workup and obviate ultrasonography in select cases. On-
line supplemental material is available for this article.
©
RSNA, 2015 • radiographics.rsna.org
Introduction
Diagnostic mammography is used to assess potential abnormali-
ties detected at screening mammography, evaluate patients who
have signs or symptoms of breast disease, and provide short-term
follow-up of patients with probably benign findings (1). Supplemen-
tal mammographic views are traditionally obtained, with targeted
breast ultrasonography (US) performed if needed (2,3). Although
this traditional diagnostic algorithm has been useful in the workup
of patients with breast abnormalities, the reported positive predictive
value of an abnormal mammographic interpretation is 21%–36% (4–
6). The average sensitivity of all combined indications for diagnostic
mammographic evaluation has been reported as approximately 85%
(7). Therefore, there is room for improvement in the diagnostic set-
ting, not only in identifying breast cancers but in avoiding unneces-
sary imaging and biopsies.
Conventional two-dimensional (2D) mammography is used for
most mammographic examinations. A major limitation of this tech-
nique is the potential overlap of tissue. This overlap occurs because
detection of the digital signal depends on the total attenuation of
the x-ray beam by the intervening tissue. Overlapping tissue can
consequently obscure an area of interest and lead to a false-negative
finding. In addition, the overlap of normal structures in the breast
2  July-August 2015 radiographics.rsna.org
TEACHING POINTS
■■ Breast cancer tumor growth patterns can vary, and tumors
may not necessarily grow concentrically. Therefore, a cancer
may be seen more clearly on only one of the two standard
DBT views. For this reason, we currently use two DBT views
for diagnostic evaluation.
■■ Breast cancers often do not appear to be as high in density
at DBT as at 2D FFDM because of the technique used. A
mass that appears to be equal density or high density on a
2D mammogram with overlapping tissue layers may appear
lower in density on a 1-mm DBT section.
■■ Breast cancers can engulf surrounding adipose tissue as they
grow. This characteristic of tumor growth is better seen at
DBT, given the thin sections used. Masses seen at DBT should
be evaluated according to their shape and margin rather than
their fat content. The presence of fat should not deter biopsy
if the shape and margin are suspicious.
■■ DBT often is effective in localization of single-view abnor-
malities.
■■ After identification of a lesion that is a known or suspected
breast cancer (BI-RADS 4C, 5, or 6), thorough examination of
the mammogram can help detect multifocal, multicentric, or
contralateral disease. The 3D information acquired at DBT can
also improve assessment of lesion size.
can create a pseudolesion, often termed a summa-
tion artifact, which prompts a false-positive result.
Digital breast tomosynthesis (DBT) is a new
imaging technology that addresses the limitation
caused by overlapping structures by acquiring a
series of low-dose projection images. Computer
reconstruction allows the reader to examine
1-mm single-section images from the volumet-
ric dataset on a workstation. This technique has
shown improved sensitivity and specificity (8)
compared with digital mammography, especially
in cases of noncalcified breast cancer, and im-
proves cancer visibility (9).
Several studies have been published regarding
reductions in breast cancer screening recall rates
(10–12) and have reported improved sensitiv-
ity and specificity with use of DBT (13–15).
Our initial DBT unit was obtained for research
purposes and was placed in our diagnostic breast
care center. Most screening mammography is
performed off site in our system. When the U.S.
Food and Drug Administration (FDA) approved
clinical use of DBT, we were able to gain experi-
ence with DBT in the diagnostic setting, with
traditional supplemental imaging available for
problem solving. This provided the opportu-
nity to learn the appearances of breast cancer at
DBT in an environment where we could also use
supplemental mammography and US. We quickly
adapted to use of DBT and found it helpful in
lesion characterization and localization and as a
staging tool for new cases of breast cancer. DBT
has helped us differentiate benign from malig-
nant imaging features of breast lesions and has
increased reader confidence in assigning a Breast
Imaging Reporting and Data System (BI-RADS)
classification, as reported in other literature (8,9).
This article describes current DBT technology
and the advantages of using DBT in a diagnostic
mammography practice.
DBT Technology
At DBT, the breast is compressed and held
stationary between the compression paddle and
the detector, in a procedure similar to that used
at digital mammography. The x-ray tube moves
in an arc overhead, executing a series of low-dose
exposures at preset intervals, each from a dif-
ferent angle. The result is a series of projection
images (Fig 1). The details of image acquisition
unique to each system have been previously
described in the literature (16). A DBT system
can acquire images in standard mammographic
orientations (ie, craniocaudal, mediolateral
oblique [MLO], and mediolateral). DBT can also
be performed with spot compression and used to
obtain implant-displaced views. DBT cannot be
performed with magnification views.
After image acquisition, DBT images can be
reconstructed into sections as thin as 1 mm in the
plane that is parallel to the detector. This process
allows three-dimensional (3D) estimation of tis-
sue distribution to help determine the location
of a lesion on the projection images in relation to
the breast tissue and compute its vertical position.
Because of the limited angle of the projection
acquisition, DBT is characterized by high spatial
resolution in the plane parallel to the detector
and lower spatial resolution in the perpendicu-
lar direction. However, spatial resolution in the
depth direction has generally been shown to be
high enough to substantially decrease the effects
of tissue superimposition (17). Objects seen in
the specific plane of each section in the stack of
reconstructed images are in focus, while objects
in planes above or below are out of focus. The
amount of blurring of a given object is propor-
tional to its distance from the currently displayed
plane and the object’s size (16).
The total number of reconstructed images will
vary depending on the thickness of the com-
pressed breast. Images are displayed on a pro-
prietary workstation as 2D image sections. This
allows the radiologist to scroll through the images
individually and manipulate the section thickness
to as thin as 1-mm intervals. Images can also be
grouped as a slab to further evaluate anatomic or
pathologic findings. Of note, five additional sec-
tions are added to the nonreceptor side of the im-
age because the edge of the breast can be difficult
to define. For example, on the craniocaudal view,
RG  •  Volume 35  Number 4 Peppard et al  3
Figure 1.  Diagram of DBT image acquisition shows
how the x-ray tube moves in a prescribed arc, execut-
ing a series of low-dose exposures of the compressed
breast tissue during a 4-second sweep.
five additional sections are added to the superior
aspect.
DBT images are most often obtained by us-
ing an FDA-approved combination acquisition
mode (18). Combination-mode imaging refers
to an acquisition mode in which 2D full-field
digital mammography (FFDM) and DBT are
performed in the same examination during the
same breast compression. DBT projection im-
ages are acquired first, followed by standard
mammographic images obtained in a neutral
perpendicular position, with no change in breast
compression. Because the images are acquired
sequentially, the 2D and 3D datasets can be
coregistered, and lesions should have the same
x- and y-axis locations on both sets of images.
An advantage of combination acquisition is cor-
relation of DBT and FFDM findings because
the reader can toggle between the 2D and 3D
datasets. Use of combination acquisition also
facilitates comparison with 2D images from prior
examinations, evaluation of left and right asym-
metry, and assessment of microcalcifications.
A synthesized 2D image reconstruction algo-
rithm (C-View 2D; Hologic, Bedford, Mass) has
recently been developed. This software is used
to create a synthesized 2D image from the DBT
dataset, which results in a lower patient radiation
dose (19). This technology has been shown to
perform comparably to combination imaging in
routine clinical screening (20).
Indications for DBT
DBT can be used for diagnostic breast exami-
nation in various clinical scenarios (21–25). In
the diagnostic setting, use of DBT can improve
lesion visibility, especially in subtle breast cancer,
and can improve reader performance beyond that
achieved at traditional diagnostic mammography.
Lesion Visibility
Several studies have shown improved visibility of
invasive breast cancers at DBT. Specifically, in a
study by Dang et al (26), 16% of invasive breast
cancers were occult at conventional mammogra-
phy, versus 3% at DBT. Therefore, DBT is useful
in depicting cancers that are subtle or occult at
conventional imaging.
Most breast cancers are visible on both
craniocaudal and MLO DBT images. However,
even at DBT, some cancers are visible on only a
single mammographic view. Breast cancer tumor
growth patterns can vary, and tumors may not
necessarily grow concentrically. Therefore, a
cancer may be seen more clearly on only one of
the two standard DBT views. For this reason,
we currently use two DBT views for diagnostic
evaluation. Previous studies have reported that
5%–9% of cancers were seen on only the cra-
niocaudal view, and 1%–2% were seen on only
the MLO view (27,28). Given this variability in
tumor visualization and the goal of fully charac-
terizing an abnormality in the diagnostic setting,
we recommend using two-view diagnostic DBT.
Mammographic visualization varies among
different types of cancers. For example, in cases
of infiltrating invasive lobular carcinoma, the
typical tumor growth pattern is single file, the tu-
mor may not form a mass, and the tumor is often
difficult to detect on a standard mammogram
(29). Comparative studies of digital mammogra-
phy versus DBT for detection of invasive lobular
carcinoma have shown increased sensitivity and
diagnostic accuracy with use of combination
DBT versus FFDM alone (25,26).
Reader Performance and Preferences
Reader performance has been examined in mul-
tiple studies that compared use of supplemental
mammography to DBT for evaluation of non-
calcified lesions (22,30). In these studies, DBT
has shown comparable or improved sensitivity,
specificity, and diagnostic accuracy compared with
conventional diagnostic mammography. Multiple
studies have shown subjective reader preference for
DBT versus conventional mammography and tra-
ditional supplemental mammography (22,23,31–
33). In most of these studies, reader preference
for DBT was equivalent or superior to reader
preference for conventional mammography, with
several studies concluding that DBT may have the
potential to replace additional spot compression
mammography. A potential decrease in use of US
4  July-August 2015 radiographics.rsna.org
has been reported with use of DBT (23). In one
study, radiologists indicated that the availability of
DBT would have eliminated use of US as part of
the diagnostic process in 12% of cases.
Overall, we have observed the same trends in our
practice. With increased reader experience, there
has been increased reader preference for DBT.
Because DBT allows the reader to see greater detail
and identify normal structures, we have observed
decreased use of additional diagnostic views and
US in select cases. For example, the fatty hilum of
an intramammary lymph node (Fig 2, Movie 1) can
become more evident at DBT, which then elimi-
nates the need for additional imaging.
Replacement for
Traditional Supplemental Imaging
Workflow benefits and certain patient factors are
important considerations in patient selection when
DBT is implemented as a substitute for traditional
supplemental mammography. During our initial use
of DBT, we obtained both FFDM spot compres-
sion and DBT images for evaluation of noncalcified
findings seen at screening and single-view find-
ings. However, we quickly noted that in most cases,
two-view DBT was sufficient for evaluation. Spot
compression images often did not yield substantial
new information, and we decreased the number of
supplemental images obtained.
Philpotts et al (34) examined diagnostic work-
flow before and after the introduction of DBT
at a dedicated breast care center and observed a
32% decrease in the number of additional images
obtained, with 72% of patients requiring no addi-
tional images when compared to a similar diag-
nostic population 1 year before DBT implementa-
tion. They concluded that use of DBT in their
facility led to faster diagnostic workups, greater
throughput, and improved resource utilization.
We have observed that as readers become more
comfortable and familiar with DBT technol-
ogy, there has been preferential use of DBT.
This improves workflow in the diagnostic setting
because it results in acquisition of fewer mammo-
graphic views and less moving of patients in and
out of mammography rooms. Radiologists and
technologists at our facility often prefer DBT for
recalled patients because it streamlines assessment
and allows global evaluation of multiple areas of
concern simultaneously in the same breast.
Patient selection for DBT in terms of breast
density is an area of ongoing interest (35,36).
DBT has shown improved accuracy across a vari-
ety of breast densities (13,35). In a large screening
study, DBT accuracy showed a relative bell curve,
with the greatest gains in diagnostic accuracy seen
in women in BI-RADS categories 2 and 3 (scat-
tered and heterogeneous breast densities) (13).
Figure 2.  Improved anatomic detail at DBT. Right craniocau-
dal DBT image shows detail of the fatty hilum in an intramam-
mary lymph node (circle). No additional evaluation is needed.
This finding makes sense because there must be
some degree of intrinsic tissue contrast in the
breast for a cancer to be visualized at DBT.
Finally, in the diagnostic setting, use of DBT
may decrease the number of lesions classified as
BI-RADS category 3. In early studies, use of DBT
in the diagnostic setting decreased the number of
lesions classified as BI-RADS category 3, particu-
larly masses and asymmetries, with a concomitant
substantial increase in the number of lesions
categorized as BI-RADS 1, 2, or 5 (37).
Contraindications for DBT
The relative contraindication for DBT is similar
to that for patients who cannot tolerate traditional
mammography. DBT requires breast compres-
sion similar to that used at standard 2D FFDM.
In a combination-mode study, a slightly longer
compression time is required to obtain both sets
of images, and some patients may not tolerate the
additional imaging time.
Practical Use of
DBT in Diagnostic Workup
Implementation of DBT in the standard diagnos-
tic workflow can provide specific benefits, as de-
tailed previously. To achieve these results, readers
must become familiar with the imaging features
of breast cancer at DBT.
Assessment of Noncalcified Cancers
There are many different imaging presentations
of breast cancer. At DBT, the imaging features
and visibility of breast cancers will be slightly dif-
ferent from those at conventional mammography.
In our practice, we use DBT to evaluate noncal-
cified lesions.
Architectural Distortion.—Architectural distor-
tion is a subtle imaging finding that often is better
visualized at DBT than at conventional mammog-
raphy. Identification of architectural distortion at
diagnostic examination is important because it has
a high positive predictive value for cancer in ap-
proximately 60% of cases (38).
RG  •  Volume 35  Number 4 Peppard et al  5
Detecting architectural distortion is often
difficult at conventional imaging, including di-
agnostic imaging, because it is a subtle sign. It
may be similar in density to surrounding tissue,
is frequently visible on only one view, and may
have areas of associated fat. Within areas of ar-
chitectural distortion, fat within a lesion is not a
characteristic benign finding (39). In addition, ar-
chitectural distortion is a frequent cause of false-
negative findings and can be missed with use of
computer-aided detection algorithms.
Architectural distortion is a common mani-
festation of cancers noted at DBT. It was the
primary finding in 12% of subtle breast cancers
noted at DBT (26). Of cancers that manifested as
architectural distortion at DBT, 50% were occult
at conventional mammography, and 20% were
characterized as an asymmetry or focal asymme-
try at conventional mammography (26). Cancers
that manifested as architectural distortion at
DBT included a higher percentage of invasive
lobular carcinomas (20%) (26).
In clinical practice, we have noted that DBT is
useful for evaluation of potential architectural dis-
tortion. DBT allows readers to visualize the radiat-
ing lines that converge to a point (Fig 3; Movies 2,
3). It is especially useful in evaluation of possible
distortion along a fat-glandular interface (Fig 4,
Movie 4) and at the apex of the breast because
summation is common in this area.
Other imaging findings that may manifest as
architectural distortion include radial scars (Fig 5;
Movies 5, 6) and postsurgical scars (Fig 6, Movie
7). Scars from biopsies performed many years
Figure 3. Improved visualization of
architectural distortion at DBT. Left cra-
niocaudal (a) and MLO (b) DBT images
show architectural distortion, with lines
radiating from a point in the middle third
of the breast at the 3-o’clock position (cir-
cle). This is a suspicious finding. Stereo-
tactic core needle biopsy demonstrated
invasive ductal carcinoma.
previously, which no longer are evident on conven-
tional mammograms, may be visible at DBT.
Focal Asymmetry.—Focal asymmetry refers to a
small amount of fibroglandular tissue in a small
portion of the breast (less than one quadrant),
which is visible on and has a similar shape on differ-
ent mammographic projections (2). The current BI-
RADS lexicon limits use of the term asymmetry to
a finding seen on only one view (2). Asymmetry is
unilateral, without a similar correlate of tissue in the
same position in the contralateral breast. DBT is
often useful for evaluation of a focal asymmetry. It
can be used to confirm and characterize a finding as
a true asymmetry, dismiss it as a superimposition,
or reclassify it as a mass. In a study by ElMaadawy
et al (40) that used DBT for evaluation of focal
mammographic asymmetry, DBT showed higher
sensitivity (93.8%) for lesion visualization and dif-
ferentiation of true lesions from summation arti-
facts than did spot compression imaging (50.2%).
There also was a higher perceived need to proceed
to US with use of spot compression views versus
DBT, and radiologists’ confidence levels for overall
assessment were significantly higher with DBT. We
have seen similar results in our own practice, where
a focal asymmetry seen at FFDM is better defined
at DBT and is reclassified as a mass (Fig 7; Movies
8, 9) or is confidently found to represent tissue
summation at DBT (Fig 8, Movie 10) (41).
Masses.—Masses are characterized by their
shape, margin, and density. These features are
often better depicted at DBT, and the reader can
6  July-August 2015 radiographics.rsna.org

Figure 4.  Improved visualization of architectural distor-

tion at DBT. (a) Right MLO DBT image shows an area of
distortion (circle) that represents contour change along
the anterior superior margin of the fibroglandular core
near the apex of the breast. (b) Close-up view of the
same DBT image section shows a focal retraction along
the margin of the tissue, at the interface of fat and pa-
renchymal tissue. (c) Targeted US image shows a hy-
poechoic mass with indistinct borders and associated dis-
tortion in the surrounding parenchyma. US-guided core
needle biopsy demonstrated invasive ductal carcinoma
with ductal carcinoma in situ.

Figure 5.  Radial scar at DBT. Left craniocaudal (a) and MLO (b) DBT images show
an area of architectural distortion (circle) in the middle third of the left breast at the
3-o’clock position. The finding was visible only at DBT. DBT-guided stereotactic biopsy
demonstrated a radial scar without atypia or malignancy.
RG  •  Volume 35  Number 4 Peppard et al  7

Figure 6.  Postsurgical scar. (a) Right

craniocaudal FFDM image shows a scar
marker (circle) that indicates an old surgi-
cal site. (b) Right craniocaudal DBT image
shows distortion in the central and lateral
middle third of the breast (circle) in the
area of the postsurgical scar. Postsurgi-
cal scar is a benign cause of architectural
distortion. We do not use skin markers at
DBT because they create imaging artifact.

Figure 7.  (a) Bilateral screening craniocaudal (left) and MLO (right) FFDM images show a focal asymmetry in the posterior superior
third of the left breast on the MLO image (arrow). (b) Left craniocaudal DBT image shows that the focal asymmetry (circle) is localized
to the lateral breast. The finding was reclassified as a mass. (c) Close-up view of the finding seen in b shows an equal-density irregular
mass with spiculated margins (circle). Biopsy demonstrated invasive ductal carcinoma.
8  July-August 2015 radiographics.rsna.org

Figure 8.  Focal asymmetry at

FFDM. Right MLO FFDM screening
image shows a focal asymmetry
Figure 9.  Improved visualization of mass shape and margin at DBT. (a) Right
(arrow) in the posterior third of the
craniocaudal FFDM image shows an indistinct mass in the central breast. (b) Right
superior right breast. The finding
craniocaudal DBT image shows an irregular mass (circle) with spiculated margins.
was shown at DBT to represent tis-
Biopsy demonstrated invasive ductal carcinoma.
sue summation.

develop a more accurate degree of suspicion be-
fore performing US.
The shape of benign and malignant lesions is
often better defined at DBT, which results in reclas-
sification of the shape category from the screening
examination (30,42). In a study by Zuley et al (30),
frequency of use of the shape descriptor “irregu-
lar” decreased significantly at DBT, with masses
reclassified at DBT as lobulated or oval. This trend
was more common with benign lesions than with
cancers. Of the cancerous lesions classified as ir-
regular at diagnostic supplemental imaging, 70%
were described as lobulated at DBT. For lesions
that had the same perceived shape at both modali-
ties, DBT images were more accurate for diagnosis
than were supplemental images.
Mass margins, including those of malignan-
cies, are shown in improved detail at DBT (Fig
9, Movie 11). DBT also is useful in characteriz-
ing masses with spiculated or indistinct margins
that were previously obscured on spot com-
pression views (Fig 10). Detection of architec-
tural distortion is often improved at DBT. The
improved detail leads to an increased degree of
suspicion, which often increases the BI-RADS
category of the mass. The individual imaging
feature of a circumscribed margin, however,
does not imply benignity.
Masses with a higher density than the expected
attenuation of an equal volume of fibroglandular
tissue at diagnostic FFDM merit a higher level of
suspicion. Although mass margins and shape are
better defined at DBT, the density of a mass may
not be as apparent on an individual DBT section
as on an FFDM image. Breast cancers often do
not appear to be as high in density at DBT as at
2D FFDM because of the technique used. There-
fore, a mass that appears to be equal density or
high density on a 2D mammogram with overlap-
ping tissue layers may appear lower in density on a
1-mm DBT section (Fig 11).
Recently, use of DBT in analysis of fat-
containing masses has been evaluated (39). In
encapsulated fat-containing masses, the presence
of fat usually implies a benign cause. Fat is often
visualized within masses at DBT, which can lead
to possible image misinterpretation. The major
part of the breast is composed of adipose tissue,
even in breasts that are extremely dense at mam-
mography. Breast cancers can engulf surrounding
adipose tissue as they grow. This characteristic
of tumor growth is better seen at DBT, given the
thin sections used. Masses seen at DBT should
be evaluated according to their shape and margin
rather than the presence of fat. The presence of
fat should not deter biopsy if the mass shape and
margin are suspicious. In these cases, it is impor-
tant to scrutinize the overall appearance of the
mass and classify it according to its most suspi-
cious features (Fig 12, Movie 12).
RG  •  Volume 35  Number 4 Peppard et al  9
Localization of Single-View Findings
A one-view asymmetry is considered suspicious
if it is new or enlarging (2). At diagnostic evalu-
ation, it is important to find the lesion on two
views for complete assessment and to target US
to the correct location. The reader must first de-
termine the depth of the finding on the visualized
view and determine whether it would be included
in the field of view on the other projection. For
example, a far-posterior lesion seen in the supe-
Figure 10.  Improved detail of
mass margins at DBT. (a) Right
craniocaudal spot compression
FFDM image shows a high-density
irregular mass with indistinct mar-
gins (circle). (b) Right craniocau-
dal DBT image allows improved vi-
sualization of the spiculated border
of the mass (circle).
Figure 11.  Differences in mass
density at DBT and FFDM. (a) Left
craniocaudal FFDM image shows
a high-density irregular mass
with indistinct margins in the left
central breast. (b) Left craniocau-
dal DBT image shows an equal-
density irregular spiculated mass.
A mass can appear less dense on
an individual DBT section than on
an FFDM image because of the
removal of overlapping tissue at
DBT. Biopsy demonstrated inva-
sive lobular carcinoma.
rior breast on an MLO view may not be included
in the field of view on a craniocaudal image.
After it is determined that the depth of the
single-view lesion should allow it to be included
on the second projection, the radiologist must
determine why the lesion is not seen. Common
reasons include tissue superimposition or obscu-
ration of the finding on the second projection. At
a traditional diagnostic mammographic workup,
readers use “best-guess” spot compression views,
10  July-August 2015 radiographics.rsna.org
Figure 12.  Visualization of fat at
DBT. (a) Left craniocaudal DBT im-
age shows an irregular ill-defined
mass with associated distortion in
the medial breast (circle). (b) Close-
up view of the same finding shows
nonencapsulated fat in the mass
(circle). The presence of fat within a
mass should not deter biopsy if the
mass shape or margin is suspicious.
Biopsy demonstrated invasive lobu-
lar carcinoma.
rolled craniocaudal views for a craniocaudal-only
finding, or true lateral (mediolateral or laterome-
dial) views for an MLO-only finding (38). Even
with the use of multiple different views, it may
still be difficult to see the finding, especially if it
is a small or low-density mass (Fig 13).
With standard DBT views, it important to
keep in mind that the MLO view is not a direct
orthogonal view. MLO views are typically ob-
tained at a 30º–60º angle, versus a true lateral
view, which is obtained at 90º. The radiologist
must mentally account for differences in posi-
tion and expected changes in position between
the MLO and mediolateral views, depending on
whether the finding is located in the medial or
lateral breast. Finally, it is important to ensure
that the breast is properly positioned, with the
nipple in profile, to determine lesion depth. Close
attention to these factors is critical because use of
DBT cannot overcome poor patient positioning
or quality issues.
DBT often is effective in localizing single-view
abnormalities. Because multiple low-dose images
are obtained in an arc, they can provide posi-
tional data. This process assigns a section number
to each tomographic image in the station. The
reader can assess where in the stack of images
the abnormality is best visualized in relation to
the image receptor, with lower numbers being
inferior on the craniocaudal view and lateral on
the MLO view (Fig 14; Movies 13, 14). Finally,
when localizing a lesion at DBT, the reader must
remember that the image set will contain five
additional sections on the nondetector side. This
should be accounted for when localizing find-
ings in the stack of images in the dataset. For
example, a lesion that is seen in the center of the
stack may actually be in a slightly more superior
location than at first glance.
Breast Cancer Staging
After a lesion is identified as known or suspected
breast cancer (BI-RADS 4C, 5, or 6), thorough
examination of the mammogram will help detect
multifocal, multicentric, or contralateral disease.
The 3D information acquired at DBT can also
improve assessment of lesion size. Mammographic
evaluation of breast cancer should include lesion
size, number of lesions, total span of disease, and
presence of contralateral disease. We often use
DBT for breast cancer staging because contrast-
enhanced magnetic resonance (MR) imaging
is used only selectively in patients with newly
diagnosed breast cancer.
Tumor Size.—Determining the mammographic
size of a cancer can be difficult. To measure tu-
mor size at DBT, the radiologist should measure
the core nucleus of the mass (43) and not include
spicules that may be seen on individual sections
(Fig 15). Several studies have shown that this
manner of DBT measurement correlates well
with pathologic analysis in masses measuring up
to 20 mm (43,44) and is more accurate than digi-
tal mammography alone (43,45), even in women
with dense breasts (44).
Number of Tumor Lesions or Satellite Lesions.—
The presence of multifocal or multicentric dis-
ease can greatly affect surgical treatment and
the choice of mastectomy or breast conservation
surgery. DBT can depict additional satellite le-
sions, given the greater visualization of detail
(Fig 16, Movie 15).
Evaluation of the Contralateral Breast.—Women
with newly diagnosed breast cancer have a 2%–3%
prevalence of contralateral breast cancer detected at
mammography. At contrast-enhanced MR imaging
RG  •  Volume 35  Number 4 Peppard et al  11

Figure 13.  Standard diagnostic

views used to localize a single-view
finding in a 50-year-old woman.
(a, b) Right craniocaudal FFDM
screening image (a) shows an
asymmetry in the central breast
(circle), with no definite correlate
seen on an MLO FFDM image (b).
(c, d) Right craniocaudal (c) and
MLO (d) spot compression images
obtained at recall show a local-
ized round equal-density mass at
the 12-o’clock position (arrow).
(e) Focused US image of the supe-
rior breast shows a simple cyst. Rou-
tine screening was recommended.

Figure 14.  DBT for localization of a single-view finding. (a) Craniocaudal DBT image in a selected section shows a mass (circle) that
was noted to be in the lower-numbered images at DBT, which indicates its position in the inferior breast and guides the search on
other views. (b) MLO DBT image shows that the mass (circle) is obscured but is likely localized to the 6-o’clock position. (c) Close-up
view of the finding in a shows an equal-density, round, circumscribed mass with associated architectural distortion. (d) Correspond-
ing US image shows a 5-mm hypoechoic suspicious mass with a microlobulated border at the 6-o’clock position. US-guided core
needle biopsy demonstrated invasive ductal carcinoma.
12  July-August 2015 radiographics.rsna.org

Figure 15.  Tumor measurement

at DBT. (a) Right craniocaudal DBT
image shows correct measurement
of the core nucleus of a tumor
(solid line). This method of mea-
surement has been shown to cor-
relate to tumor size at pathologic
analysis in tumors up to 20 mm.
(b) Same DBT image shows incor-
rect measurement (dashed line)
that includes fine spicules extend-
ing from the core of the mass. This
measurement overestimates the
size of the tumor compared with
findings at pathologic analysis.

Figure 16.  Assessment of mammographic extent of disease at DBT in a woman with invasive ductal carcinoma. (a) Four-view
bilateral FFDM images show an irregular high-density mass in the posterior third of the upper outer quadrant of the right breast
at the 10-o’clock position (circles). CC = craniocaudal. (b) Right craniocaudal DBT image shows a dominant, spiculated, irregular
mass (black circle) and two additional posterior and medial masses (white circles) that were not visible at FFDM. (c, d) Targeted
US images obtained at different locations in the breast show the two satellite lesions.
RG  •  Volume 35  Number 4 Peppard et al  13
to evaluate patients with new breast cancer, an ad-
ditional 3%–5% of women have mammographically
occult contralateral breast cancer (46).
In patients with newly diagnosed breast can-
cer, we routinely reexamine the patient’s images
as part of the staging process and scrutinize
images of the contralateral breast for subtle
mammographic findings of cancer. Because we
do not routinely perform contrast-enhanced MR
imaging to evaluate the contralateral breast in all
new breast cancer cases, DBT has proven useful
in evaluation of the contralateral breast (Fig 17;
Movies 16, 17).
Figure 17.  Contralateral cancer
detected at follow-up DBT in a
patient with BI-RADS category 3
subareolar calcifications in the left
breast. (a, b) Right and left cra-
niocaudal (CC) (a) and MLO (b)
FFDM images obtained at short-
term follow-up show a new find-
ing of a mass with associated cal-
cifications at the 2-o’clock position
in the upper outer quadrant of the
left breast. The patient requested
DBT in addition to standard diag-
nostic imaging. (c) Craniocaudal
DBT image shows an oval, circum-
scribed, equal-density mass with
associated grouped fine pleomor-
phic calcifications in the lateral
left breast. (d) Left craniocaudal
magnification image shows the
fine pleomorphic calcifications,
which were equally visible at DBT
and FFDM. Pathologic analysis
demonstrated ductal carcinoma in
situ associated with an intraductal
papilloma. (e) Right craniocaudal
DBT image shows an irregular,
spiculated, equal-density mass not
visible at FFDM. (f) Targeted US
image shows a highly suspicious
mass in the right breast. US-guided
core needle biopsy demonstrated
invasive ductal carcinoma.
Potential
Limitations and Drawbacks
There are several potential limitations and practical
drawbacks for implementing DBT in the diagnostic
setting. The patient’s breast size may affect the abil-
ity to perform DBT. A patient who undergoes DBT
must have a compressed breast thickness of more
than 2 cm; therefore, some patients will not qualify.
The breasts of larger patients may exceed the detec-
tor size requirements for global diagnostic DBT.
In these patients, we obtain a single DBT image in
each projection by positioning the area of interest
and/or areas with dense parenchymal tissue within
14  July-August 2015 radiographics.rsna.org

Figure 18.  Occult breast cancer in dense breast

tissue in a 45-year-old woman who presented
with a palpable left breast mass found at self-ex-
amination. (a, b) Spot compression craniocau-
dal (a) and MLO (b) DBT images obtained after
normal findings were seen at DBT show the pal-
pable area (marked by triangle) at the 12-o’clock
position. No mammographic abnormality was
noted. (c) Targeted US image of the palpable
area shows a suspicious complex mass with in-
distinct borders at the 12-o’clock position, 1 cm
from the nipple. US-guided core needle biopsy
demonstrated intracystic papillary carcinoma.

the field of view to gain maximum benefit from the

technique. Potential false-negative findings related
to technique can result from extremely dense tis-
sue that obscures the finding. For DBT to be used
effectively, there must be some interface between
parenchymal and adipose tissue in the breast. If the
finding is centered in extremely dense tissue that
continues to overlap on the individual sections, this
will result in a mammographically occult cancer,
despite the use of DBT (Fig 18; Movies 18, 19).
DBT provides variable visualization of microcal-
cifications (47–49), with current recommendations
that dedicated magnification views be obtained for
characterization. We have found it helpful in clinical
practice to adjust the slab thickness in the image
stack when evaluating calcifications. Viewing images
as a slab can help in visualizing and determining the
distribution of calcification. This mode of viewing
helps overcome the thin-slice effect (48–50). This
term describes a cluster of calcifications that are not
as well visualized as they would have been if shown
together on a conventional 2D image. On DBT sec-
tions, only a limited number of calcifications may
be depicted, which leads to decreased visualization
and potentially poor characterization. The slab
viewing technique may also be helpful for visual-
izing spatial distribution (eg, in cases of vascular
calcification) and elucidating the linear and seg-
mental distribution of calcifications when determin-
ing extent of disease.
As with conventional mammography, there
will be errors in perception and characteriza-
tion of lesions seen at DBT. Radiologists could
mischaracterize a lesion as potentially benign be-
cause of individual features (eg, fat in the lesion
or a circumscribed margin), despite the presence
of other suspicious features.
We currently use two-view DBT as a global
study. This is in contrast to most supplemental
mammographic views, which are localized to an
area of concern. On occasion, the initial finding
of concern will not persist, but a second finding
is detected at DBT that is subsequently found to
be malignant. Review of the entire image should
be performed.
DBT can be used with spot compression to a
specific area of the breast as needed. The choice
of field of view should be made at the discretion
of the reader. However, if DBT is routinely per-
formed in this manner, some potential benefits,
especially related to characterization for extent of
disease, may be lost. If global and spot compres-
sion DBT are performed, there is a substantial
increase in the number of images obtained and
the radiation dose.
There is concern for increased radiation dose
to the patient with use of DBT. When DBT is
used in combination mode with FFDM, the
patient’s radiation dose is increased by roughly a
RG  •  Volume 35  Number 4 Peppard et al  15
factor of two compared with the dose at FFDM
alone (51,52). Use of DBT-reconstructed
pseudo-FFDM synthesized images is estimated
to potentially reduce the radiation dose by
40%–50% (53); however, this technology is not
yet available at all sites that offer DBT.
Other factors to consider on a center-by-center
basis are the cost and availability of DBT equip-
ment, storage, and interpretation time. These fac-
tors are outside the scope of this article and have
been discussed elsewhere. Mammography depart-
ments that use DBT should develop an algorithm
to triage patients who may be best served by use
of DBT. Daily usage of DBT must be evaluated at
each center, including the need for screening ver-
sus diagnostic imaging, on the basis of the facility’s
patient population and resources. Use of screening
DBT has been discussed recently in the literature
(13,16,54). Finally, biopsy of DBT-only findings is
a concern. An add-on DBT stereotactic guidance
system (Affirm; Hologic) has been developed;
however, this system is not yet available at all sites
that offer DBT.
Conclusion
DBT is a useful tool in diagnostic evaluation
and staging of breast cancer. It can be used to
further characterize suspicious lesions and im-
prove diagnostic accuracy and reader confidence.
However, as with any new technique, readers must
become familiar with subtle changes in imag-
ing findings at DBT versus FFDM to accurately
characterize and classify lesions. DBT is useful for
problem solving in patients with suspicious findings
and can help localize a single-view finding.
In breast cancer staging, we have found DBT to
be a useful technique for better understanding the
3D structure of an invasive cancer. This can lead
to improved preoperative sizing of lesions, identi-
fication of additional satellite lesions, and evalua-
tion of the contralateral breast. Limitations of the
technique can be seen, including patient inability
to tolerate the examination and difficulty depicting
findings in extremely dense tissue. We have found
that DBT is a useful diagnostic tool for women
with new or suspected breast cancer.
Disclosures of Conflicts of Interest.—H.R.P. Activities
related to the present article: disclosed no relevant rela-
tionships. Activities not related to the present article: grant
from Hologic, consultant for Siemens. Other activities:
disclosed no relevant relationships. J.A.H. Activi-
ties related to the present article: disclosed no relevant
relationships. Activities not related to the present article:
shareholder in and research agreement with Hologic.
Other activities: disclosed no relevant relationships.
J.K.M. Activities related to the present article: disclosed
no relevant relationships. Activities not related to the
present article: consultant for Siemens. Other activities:
disclosed no relevant relationships.
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TM