Wo m e n ’s I m a g i n g • C l i n i c a l Pe r s p e c t i ve

Zuckerman et al.
Synthesized 2D and Digital Mammography

Women’s Imaging
Clinical Perspective

Imaging With Synthesized 2D

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Mammography: Differences,
Advantages, and Pitfalls Compared
With Digital Mammography
Samantha P. Zuckerman1 OBJECTIVE. Synthesized 2D (s2D) mammography is rapidly replacing digital mam-
Andrew D. A. Maidment mography in breast imaging with digital breast tomosynthesis (DBT) to reduce radiation dose
Susan P. Weinstein and maintain screening outcomes. We illustrate variations in the appearance of s2D and digi-
Elizabeth S. McDonald tal mammograms to aid in implementation of this technology.
Emily F. Conant CONCLUSION. Despite subjective differences in the appearance of s2D and digital
mammograms, early outcomes of screening using s2D mammography and DBT are not infe-
Zuckerman SP, Maidment ADA, Weinstein SP, rior to those achieved with digital mammography and DBT. Understanding these variations
McDonald ES, Conant EF may aid in implementing this technique and improving patient outcomes.

igital breast tomosynthesis (DBT), to that for CT scans or maximum-intensity-

Keywords: digital breast tomosynthesis, digital

mammography, screening, synthesized 2D mammography
DOI:10.2214/AJR.16.17476
Received October 4, 2016; accepted after revision
December 24, 2016.
Based on a presentation at the Radiological Society of
North America 2015 annual meeting, Chicago, IL.
Supported by the National Cancer Institute at the
National Institutes of Health Population-based Research
Optimizing Screening through Personalized Regimens
(PROSPR) Network (U54CA163313).
A. D. A. Maidment receives payment from Gamma
Medica and Real-time Tomography for board member-
ship, has grants from the Komen Foundation and NIH,
receives payment for lectures including speakers
bureaus of University of Washington and University of
North Carolina, and owns stock options in Real-time
Tomography. S. P. Weinstein receives consulting fees
from Siemens Healthcare. E. F. Conant receives
consulting fees from Hologic and Siemens Healthcare.
1 39–45% decrease in radiation exposure [7–
All authors: Department of Radiology, Division of Breast
Imaging, Hospital of the University of Pennsylvania,
3400 Spruce St, 1 Silverstein, Philadelphia, PA 19104.
Address correspondence to S. P. Zuckerman
(samantha.zuckerman@uphs.upenn.edu).
This article is available for credit.
AJR 2017; 209:222–229
0361–803X/17/2091–222
© American Roentgen Ray Society
D combined with digital mammog-
raphy, has been shown in observ-
er studies and prospective trials
to decrease recall and increase invasive can-
cer detection rates in breast cancer screening
[1–6]. Although this modality decreases
false-positive and false-negative rates, be-
cause it is a dual-acquisition study, it
significantly increases patient radiation dose
[7–10]. Several vendors now offer the capa-
bility to reconstruct synthesized 2D (s2D)
mammograms from the DBT dataset as a re-
placement for digital mammography. This
option decreases dose while maintaining the
benefits of digital mammography: rapid
global assessment of the breasts for density
assessment, lesion detection (especially cal-
cifications and asymmetries), and easier side-
by-side comparison of both breasts as well as
with prior studies. With the elimination of
the digital mammography component of the
examination, patients receive radiation only
from the DBT component, representing a
10] (Table 1).
Our institution uses the Selenia Dimen-
sions system (Hologic) for DBT imaging.
This system allows combination studies in
which DBT and digital mammography im-
ages are acquired in a single compression or
DBT-only studies in which only DBT images
are acquired and s2D mammograms are re-
constructed from the DBT dataset. The pro-
cess of creating s2D mammograms is similar
projection MR images; the slices that con-
stitute the DBT examination are backpro-
jected onto a plane to create a single image
[11–13]. The backprojection algorithm is de-
signed to maintain voxels with high attenua-
tion value and to enhance areas detected by
computer-aided detection algorithms [11–
15]. High-contrast areas, geographic linear
areas, glandular tissue, and calcifications are
accentuated on s2D mammograms, mak-
ing them more apparent to the reader. Be-
cause these images are reconstructed, nor-
mal structures and abnormalities may appear
differently than on digital mammograms,
even if images are acquired during the same
breast compression.
Early reader studies found lower sensitiv-
ity and comparable specificity for s2D and
digital mammography when combined with
DBT [12], but later reader studies found com-
parable performance between both imaging
combinations [9, 16]. An additional reader
study found no difference when comparing
thick and thin DBT slices, a proxy for s2D
mammography (Stork et al., presented at the
Radiological Society of North America 2015
annual meeting). Finally, phantom studies
comparing image quality of s2D and digi-
tal mammograms found that the former had
lower high-contrast spatial resolution than
the latter [15].
At our institution, we are in our sixth
year of screening with DBT and our second
year of screening with s2D mammography.

222 AJR:209, July 2017

 Synthesized 2D and Digital Mammography
TABLE 1: Comparison of Mean Glandular Dose of Digital Mammography
(DM) Combined With Digital Breast Tomosynthesis (DBT) and
DBT Alone
DM Combined With DBT
Study (mGy)
Zuckerman et al. [7] 1.89 + 2.21
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Skaane et al. [9] 1.58 + 1.95
Michell et al. [10] 1.37–1.57 + 1.66–1.90
While implementing s2D mammography,
we allowed a 4-month overlap period dur-
ing which patients were screened with both
digital and s2D mammography in addition
to DBT so that our physicians could become
accustomed to the appearance of the recon-
structed s2D mammograms across the diver-
sity of breast densities, thicknesses, and le-
sion types. Although our overall recall rate
has decreased and our cancer detection rate
has stayed stable with DBT and s2D, we have
found subjective differences between both
modalities [7]. This article will discuss our
experience with this new modality based on
breast density and lesion types.
Breast Density
We have noticed a qualitative difference
in s2D (Figs. 1A and 1C) and digital (Figs.
1B and 1D) mammograms in patients with
the extremes of breast density (i.e., extreme-
ly dense breasts and almost entirely fatty
breasts) and with extremes of breast thick-
ness during compression (extremely thick
and very thin). In addition, we have found
that some structural components of the
breasts such as Cooper ligaments and ves-
sels appear more pronounced and denser on
s2D mammography, often mimicking calcif-
ic lesions. This difference is likely a result
of the postprocessing software used for s2D
mammography: linear elements such as lig-
aments and vascular structures may be en-
hanced, making them appear more conspic-
uous [11–15]. Additionally, some glandular
elements appear to have sharper margins on
s2D mammograms, with greater differentia-
tion between glandular tissue and breast fat.
Increased breast density is an independent
risk factor for breast cancer [17–19]. Prelimi-
nary research at our institution has not found
differences in cancer detection rates in the
two types of screening [7], but subanalysis by
density category has not yet been performed
due to limited cancer data across all densi-
ty categories for s2D mammography. We ex-
pect that with s2D mammography and DBT,
the cancer detection rate in dense breasts will
AJR:209, July 2017
DBT Alone (mGy) % Decrease
2.44 39
1.95 45
1.66–1.90 45
be comparable with that achieved with digi-
tal mammography and DBT because the in-
formation obtained in the DBT image stack
increases the conspicuity of areas of archi-
tectural distortions and masses that may be
masked on digital mammography. In addi-
tion, s2D mammograms reconstructed from
the DBT dataset using postacquisition pro-
cessing may enhance some of these findings.
Calcifications
Forty-six percent of screen-detected
breast cancers are detected as calcific lesions
on mammography [20]. Detecting suspicious
calcifications is critical in a screening prac-
tice because some clinically significant ma-
lignancies may only be detected as calcifica-
tions. In reader studies, DBT has a varying
ability to detect calcifications when com-
pared with digital mammography [21, 22].
Improved detection with digital mammogra-
phy in some clinical situations may be par-
tially due to the higher spatial resolution of
digital mammograms (70-μm pixel size)
compared with the reconstructed tomosyn-
thesis slices. The Hologic system we use
reconstructs DBT images from images ac-
quired with 2 × 2 pixel binning (140 μm).
The pixels in the reconstructed s2D mam-
mograms are on the order of 90 μm. Thus,
s2D mammography resolution is limited by
the pixel size of the DBT images. Several
authors have expressed concerns regarding
the detection and characterization of calci-
fications with s2D mammography [15, 23].
A phantom study found that s2D mammog-
raphy enhanced medium and large calcifi-
cations when compared with digital mam-
mography but had a measureable loss of
resolution in small microcalcifications [15].
The reconstruction algorithm that creates
s2D mammograms enhances focally dense
objects when compared with digital mam-
mography. We have anecdotally found that
calcifications are more readily apparent on
the reconstructed images, often making it
easier for the reader to detect calcifications
on s2D (Fig. 2A) than on digital (Fig. 2B)
mammography. Conversely, enhanced lin-
ear breast parenchymal densities can lead to
false-positive detection of calcification; for
example, dense ligaments may appear cal-
cific on s2D mammography (Fig. 2C) but as
normal structures on digital mammography
(Fig. 2D). Additionally, dense breast tissue
can appear to be calcium on s2D mammogra-
phy (Fig. 2E) but will be identified as normal
parenchyma on digital mammography (Fig.
2F). Readers should be aware of this phe-
nomenon when analyzing lesions that appear
to be calcific on s2D mammograms and care-
fully correlate the appropriate location on
the orthogonal screening s2D mammograms
and individual corresponding DBT slice im-
ages. Often, when scrolling through the DBT
stack, false-positive calcifications seen on the
s2D mammograms can be identified as nor-
mal structures, such as ligaments or sharply
marginated vessel walls, preventing a poten-
tial false-positive callback. We found an over-
all decrease in recall rate from calcifications
in our screening practice after the addition of
s2D mammography [7]. Further research is
needed to determine if the overall decrease in
recall rate of calcific lesions is indeed associ-
ated with a decrease in false-positives rather
than an increase in false-negatives from lack
of detection or incorrect characterization of
clinically significant calcific lesions [24]. In
one study of different screening approaches,
though overall sensitivity was the same with
s2D mammography as with a combination
of digital mammography and DBT and with
digital mammography alone, the specificities
of s2D mammography and digital mammog-
raphy combined with DBT were significant-
ly higher than that of digital mammography
alone [23]. However, in subanalyses by cancer
size and subtype, s2D mammography com-
bined with DBT was inferior to both a combi-
nation of digital mammography and DBT and
digital mammography alone in the detection
of microcalcifications for 11- to 22-mm duc-
tal carcinoma in situ [23]. Larger studies with
longer follow-up are necessary to determine
if the reduction in recall of calcium cases is,
in part, due to a decrease in detection of clini-
cally significant calcific lesions.
Architectural Distortion, Masses,
and Asymmetries
Much of the improvement in screening
outcomes achieved with DBT is the result
of better differentiation between overlap-
ping glandular tissue and subtle asymmetries,
distortions, and margin characterization of
223

masses. By scrolling through the reconstruct-
ed DBT slices, readers are able to more confi-
dently differentiate between a discrete lesion
and overlapping normal glandular tissue. A
subtle asymmetry that is obscured by glandu-
lar tissue on digital mammography (Fig. 3B)
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is better seen on s2D mammography (Fig.
3A) because of the reconstruction algorithm
that emphasizes distortions and margins of
the mass compared with the overlying tis-
sue. A malignant mass that appears similar
to glandular tissue on digital mammograms
(Fig. 3D) has angulated borders and associat-
ed distortion on s2D mammograms (Fig. 3C).
Additionally, subtle architectural distortion
appears similar to glandular tissue on digital
mammography (Fig. 4B), with enhanced ra-
diating spicules on s2D mammography (Fig.
4A), making it more conspicuous.
However, normal structures superimposed
on glandular tissue, such as ligaments, can
also be accentuated by the s2D mammogra-
phy reconstruction algorithm and appear as
distortion (Figs. 4C–4F). Careful correlation
with the corresponding location in the DBT
image set is necessary for triangulation, con-
firmation, and characterization. If the patient
is called back for distortion seen on screening
s2D mammography but neither on the screen-
ing DBT image set nor on diagnostic imag-
ing (which may include DBT spot views and
diagnostic ultrasound), the questioned distor-
tion is more likely due to enhancement in the
s2D mammography reconstruction algorithm
than to a true lesion, and the patient may be
returned to routine follow-up. However, if a
distortion is seen on the s2D mammogram as
well as the DBT source images but not on di-
agnostic imaging (including DBT spot com-
pression, which may efface true lesions), a
complete workup including ultrasound and
possible biopsy is necessary.
Technical Factors: Metal
Artifact, Motion Artifact, and
Breast Augmentation
As on CT, attenuating objects within
breasts like biopsy clips, surgical clips from
prior lumpectomy, and large dense calcifica-
tions can cause artifacts in DBT images and
then in the reconstructed S2D images (Figs.
5B and 5C). Comparable artifacts do not ap-
pear on digital mammography (Fig. 5A). Be-
cause s2D mammograms are created from
the DBT imaging acquisition, artifacts seen
on DBT persist on s2D mammography. Two
artifacts are commonly seen: zipper artifact
(Figs. 5B and 5C), which arises from repe-
224
Zuckerman et al.
tition of attenuating out-of-plane structures
analogous to view aliasing in CT images
caused by view undersampling, and shadow-
ing (Figs. 5B and 5C), which arises from the
nonlinear behavior of edge-enhancement fil-
ters used in the reconstruction process. The
resulting dark lines that emanate from highly
radiopaque objects in DBT could obscure un-
derlying breast tissue or calcifications, mak-
ing evaluation of the tissue beyond the metal
on each projection difficult. An iterative re-
construction algorithm has been developed
to help reduce this artifact on s2D mammog-
raphy (Fig. 5C). While this algorithm largely
eliminates the zipper artifact, shadowing is
decreased but still evident.
Both DBT and digital mammography can
be affected by patient motion, especially if
images are acquired during the same com-
pression. However, patient motion may af-
fect the s2D mammograms more significant-
ly than digital mammograms because of the
longer acquisition time needed to acquire the
DBT dataset. If there is sufficient patient mo-
tion during the DBT acquisition, breast paren-
chymal structures will be blurred on the s2D
mammogram (Fig. 6), resulting in loss of im-
age resolution and reduced ability to detect
small abnormalities, such as microcalcifica-
tions, and fine parenchymal features. This ef-
fect can be difficult to discern on reconstruct-
ed s2D mammograms and may be a pitfall of
imaging with s2D mammography and DBT.
Digital mammography is less prone to this
disadvantage because of the shorter exposure
time. If motion is suspected to have affected
s2D mammograms, DBT projection images
should be reviewed to see if gross patient mo-
tion is detected. In addition, radiopaque calci-
fications and surgical and biopsy clips can be
checked for “zig-zag” artifacts along the axis
of imaging parallel to the chest wall, reflect-
ing patient motion during image acquisition.
Technologists need to recognize such motion
in both s2D mammography and DBT before
completing studies so that repeat imaging can
be performed. Otherwise, patients may need
to be recalled for repeat imaging to achieve a
technically adequate study.
Conclusion
Although subjective and objective differ-
ences have been found in image quality be-
tween s2D and digital mammography, early
studies concluded that screening with s2D
mammography and DBT is not inferior to
screening with digital mammography and
DBT. Replacing digital mammography with
s2D mammography has decreased recall
rates and maintained cancer detection rates
[7]. As with transitioning from film to digital
mammography, transitioning from digital to
s2D mammography improves mammograph-
ic screening by reducing total radiation dose
and maintaining cancer detection. The sub-
jective and objective differences in the ap-
pearances of s2D and digital mammography
can be overcome with careful clinical imple-
mentation that includes a period of overlap
during which patients are imaged with both
techniques as well as DBT so that careful
comparison of the different appearances of
various breast and lesion types may be made.
References
1. Skaane P, Bandos AI, Gullien R, et al. Compari-
son of digital mammography alone and digital
mammography plus tomosynthesis in a popula-
tion-based screening program. Radiology 2013;
267:47–56
2. Friedewald SM, Rafferty EA, Rose SL, et al.
Breast cancer screening using tomosynthesis in
combination with digital mammography. JAMA
2014; 311:2499–2507
3. Conant EF, Beaber EF, Sprague BL, et al. Breast
cancer screening using tomosynthesis in combi-
nation with digital mammography compared to
digital mammography alone: a cohort study with-
in the PROSPR consortium. Breast Cancer Res
Treat 2016; 156:109–116
4. McDonald ES, Oustimov A, Weinstein SP, et al.
Effectiveness of digital breast tomosynthesis
compared with digital mammography: outcomes
analysis from 3 years of breast cancer screening.
JAMA Oncol 2016; 2:737–743
5. Ciatto S, Houssami N, Bernardi D, et al. Integration
of 3D digital mammography with tomosynthesis for
population breast-cancer screening (STORM): a
prospective comparison study. L­ ancet Oncol 2013;
14:583–589
6. McCarthy AM, Kontos D, Synnestvedt M, et al.
Screening outcomes following implementation of
digital breast tomosynthesis in a general-popula-
tion screening program. J Natl Cancer Inst 2014;
106:dju316
7. Zuckerman SP, Conant EF, Keller BM, et al. Imple-
mentation of synthesized two-dimensional mam-
mography in a population-based digital breast to-
mosynthesis screening program. R ­ adiology 2016;
281:730–736
8. Svahn TM, Houssami N, Sechopoulos I, Mattsson
S. Review of radiation dose estimates in digital
breast tomosynthesis relative to those in two-view
full-field digital mammography. Breast 2015;
24:93–99
9. Skaane P, Bandos AI, Eben EB. Two-view digital
AJR:209, July 2017
 Synthesized 2D and Digital Mammography

breast tomosynthesis screening with synthetically
reconstructed projection images: comparison
with digital breast tomosynthesis with full-field
digital mammographic images. Radiology 2014;
271:655–663
10. Michell MJ, Iqbal A, Wasan RK, et al. A compari-
Downloaded from www.ajronline.org by 202.90.133.142 on 03/17/24 from IP address 202.90.133.142. Copyright ARRS. For personal use only; all rights reserved
7,760,924. July 20, 2010
14. van Schie G, Mann R, Imhof-Tas M, Karssemeijer
N. Generating synthetic mammograms from re-
constructed tomosynthesis volumes. IEEE Trans
Med Imaging 2013; 32:2322–2331
15. Nelson JS, Wells JR, Baker JA, Samei E. How
with time, age, and menopause status. J Natl
­Cancer Inst 1995; 87:1622–1629
20. Venkatesan A, Chu P, Kerlikowske K, Sickles EA,
Smith-Bindman R. Positive predictive value of spe-
cific mammographic findings according to reader
and patient variables. Radiology 2009; 250:648–657

son of the accuracy of film-screen mammography,
full-field digital mammography, and digital breast
tomosynthesis. Clin Radiol 2012; 67:976–981
11. [No authors listed]. P080003/S001 Hologic Sele-
nia Dimensions C-View software module: sponsor
executive summary. U.S. Food and Drug Adminis-
tration website. www.fda.gov/downloads/Advisory​
Committees/Committees​Meeting​Materials/Medical​
Devices/Medical​D evices​Advisory​C ommittee/
Radiological​Devices​Panel/UCM516913.pdf. Pub-
lished October 24, 2012. Accessed June 1, 2016
12. Gur D, Zuley ML, Anello MI, et al. Dose reduc-
tion in digital breast tomosynthesis (DBT) screen-
ing using synthetically reconstructed projection
images: an observer performance study. Acad
­Radiol 2012; 19:166–171
13. Ruth C, Smith A, Stein J, inventors; Hologic, as-
signee. System and method for generating a 2D
image from a tomosynthesis data set. US patent
does c-view image quality compare with conven-
tional 2D FFDM? Med Phys 2016; 43:2538
16. Zuley ML, Guo B, Catullo VJ, et al. Comparison of
two-dimensional synthesized mammograms versus
original digital mammograms alone and in combi-
nation with tomosynthesis images. ­Radiology 2014;
271:664–671
17. Porter GJ, Evans AJ, Cornford EJ, et al. Influence
of mammographic parenchymal pattern in screen-
ing-detected and interval invasive breast cancers
on pathologic features, mammographic features,
and patient survival. AJR 2007; 188:676–683
18. Boyd NF, Byng JW, Jong RA, et al. Quantitative
classification of mammographic densities and
breast cancer risk: results from the Canadian Na-
tional Breast Screening Study. J Natl Cancer Inst
1995; 87:670–675
19. Byrne C, Schairer C, Wolfe J, et al. Mammo-
graphic features and breast cancer risk: effects
21. Kopans D, Gavenonis S, Halpern E, et al. Calcifi-
cations in the breast and digital breast tomosyn-
thesis. Breast J 2011; 17:638–644
22. Spangler ML, Zuley ML, Sumkin JH, et al. Detec-
tion and classification of calcifications on digital
breast tomosynthesis and 2D digital mammogra-
phy: a comparison. AJR 2011; 196:320–324
23. Gilbert FJ, Tucker L, Gillan MG, et al. The
­TOMMY trial: a comparison of TOMosynthesis
with digital MammographY in the UK NHS Breast
Screening Programme—a multicentre retrospective
reading study comparing the diagnostic perfor-
mance of digital breast tomosynthesis and digital
mammography with digital mammography alone.
Health Technol Assess 2015; 19:i–xxv, 1–136
24. Farshid G, Sullivan T, Downey P, Gill PG, Pieterse
S. Independent predictors of breast malignancy in
screen-detected microcalcifications: biopsy results
in 2545 cases. Br J Cancer 2011; 105:1669–1675

A B C D
Fig. 1—Examples of appearances of fatty and dense breast tissue on synthesized 2D and digital mammography.
A and B, Synthesized 2D (A) and digital (B) mammograms of predominantly fatty thick breast of 62-year-old woman undergoing screening.
C and D, Synthesized 2D (C) and digital (D) mammograms of extremely dense thin breast of 48-year-old woman undergoing screening.

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A B C D

Fig. 2—Examples of true- and false-positive calcifications.

A and B, 43-year-old woman with true-positive calcifications detected at
screening. On synthesized 2D (s2D) mammogram (A), calcifications (ovals) are
enhanced and of increased optical density relative to digital mammogram (B).
Diagnosis was high nuclear grade ductal carcinoma in situ with associated
comedonecrosis. Arrows and insets show digital zoom (A, ×2.6; B, ×3.5).
C and D, 56-year-old woman with false-positive finding of calcifications at
screening. Ligament is enhanced in s2D mammogram (C) and appears as possible
linear calcifications (oval), but no calcifications are seen on digital mammogram
(D) obtained after recall. Arrow and inset in C show digital zoom (×2.8).
E and F, 57-year-old woman with false-positive finding of calcifications at
screening. Possible new, grouped calcifications (ovals) are seen on craniocaudal
view of s2D mammogram (E). Digital mammography magnification view (F)
obtained after recall shows single dystrophic calcification remains; questionable
new calcifications are shown to be dense areas of fibroglandular tissue. Arrows
and insets show digital zoom (E, ×2.2; F, ×3.4).
E F

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A B C D
Fig. 3—Examples of asymmetries and masses.
A and B, 51-year-old woman with skin biopsy of areola showing infiltrating adenocarcinoma. Architectural distortion and asymmetry (ovals) are better seen on
synthesized 2D (s2D) mammogram (A) than on digital mammogram (B). Final diagnosis was high-grade invasive ductal cancer. Arrows and insets show digital zoom (A,
×1.6; B, ×1.8).
C and D, 54-year-old woman with spiculated mass (ovals) that is seen better on screening s2D mammogram (C) than on digital mammogram (D). Final diagnosis was
intermediate-grade invasive ductal carcinoma. Arrows and insets show digital zoom (C, ×1.7; D, ×1.5).

Fig. 4—True- and false-positive architectural distortion on screening images.

A and B, 60-year-old woman with true-positive architectural distortion (ovals)
that is better seen on synthesized 2D (s2D) mammogram (A) than on digital
mammogram (B). Final diagnosis was invasive ductal and invasive lobular
carcinoma. Arrows and insets show digital zoom (A, ×1.9; B, ×2.8) .
A B (Fig. 4 continues on next page)

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C D E F
Fig. 4 (continued)—True- and false-positive architectural distortion on screening images.
C and D, 63-year-old woman with false-positive architectural distortion. Patient was called back because of apparent area of distortion (circle, C) on s2D mammogram (C)
that was not seen on digital breast tomosynthesis (DBT) source images. No abnormality was identified on digital mammography compression view (D) or ultrasound (not
shown) performed after patient was recalled. Distortion on s2D mammography represented overlapping glandular tissue. Arrow and inset in C show digital zoom (×1.5).
E and F, 45-year-old woman with distortion (circle, E) seen in upper posterior breast on mediolateral oblique s2D mammogram (E) but not on DBT. Digital mammogram (F)
obtained after patient was recalled confirms findings from DBT: Overlapping vascular and glandular tissue (circle, F) created appearance of architectural distortion.

A B C
Fig. 5—40-year-old woman presenting with palpable lump after mastectomy with transverse rectus abdominis myocutaneous reconstruction. Fat necrosis was seen in
area of concern.
A, Metal artifact is not present on digital mammography.
B and C, Metal artifact is seen on synthesized 2D mammography images. On image without reconstruction algorithm (B), both zipper artifact (solid arrow) and shadowing
artifact (open arrow) are apparent. On image with reconstruction algorithm (C), zipper artifact (solid arrow) is less apparent, but shadowing artifact (open arrow) remains.

228 AJR:209, July 2017

 Synthesized 2D and Digital Mammography

Fig. 6—Motion artifact in images of 44-year-old

woman undergoing screening.
A and B, Synthesized 2D (s2D) and digital
mammograms obtained during same compression
were both affected by patient motion. However, s2D
mammogram (A) is less sharp overall than digital
mammogram (B). Greater effect of patient motion
on s2D mammography results from longer image
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acquisition time for digital breast tomosynthesis than

that for digital mammography.

A B

F O R YO U R I N F O R M AT I O N
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AJR:209, July 2017 229