3D DIGITAL BREAST

TOMOSYNTHESIS (DBT)

PRESENTER: Dr. B S Ashith Kumar, PGY-1

MODERATOR: Dr. Naren Chakravarthy, SR
Department of Radiodiagnosis, NMC
 Contents
1. Principles
2. Technique
3. Advantages
4. Limitations
5. Current Screening Guidelines
 Why was it developed?
• Limited sensitivity of conventional Digital
Mammography (DM) in Women with dense
breast tissue
• Relatively high number of patients called
back from screening for additional imaging
(Recall Rate)
 How is it different from 2D
Mammogram?
• Adds another dimension – DEPTH of
tissue

• Multiple slices of Breast tissue at

different angles

• FDA approved DBT as a

supplementary technique to 2D Full-
field digital mammography (2D
FFDM) in 2011 for breast cancer
screening and diagnosis
 Principles
• 2D imaging (FFDM) > FFDM
anatomical noise due to
superimposition of normal
anatomy and pathological
changes > OBSCURATION of
Pathology or
PSEUDOMASSES
• DBT > Multiple projection
radiographs at different
angles> BETTER DELINEATION
OF PATHOLOGIES
OBSCURATION OF
PATHOLOGY
PSEUDOMASS
 Technique
• Unlike FFDM, X-ray tube rotates
in arc (15-60 ) – SWEEP ANGLE
• LOW DOSE multiple projections
at different angles DBT

FFDM
• X-ray exposure: CONTINUOUS or
STEP AND SHOOT

A) CONTINUOUS:
- reduces acquisition time
- decreases resolution
because of focal spot
blur(MOTION)

B) STEP & SHOOT:

- long time for acquisition
- However, prone for MOTION
ARTEFACT
 Microcalcifications missed?

• For same radiation dose and No. of

projections,

A) More the SWEEP ANGLE,

- better tomographic
separation & Z- axis resolution
> masses delineated well
- Reduces In-plane
resolution > misses
microcalcifications

B) Less the SWEEP ANGLE,

- more projections > Inc.
radiation dose
• Multiple 1mm thickness slices >
reconstructed by FILTERED BACK PROJECTION
or ITERATIVE RECONSTRUCTION ALGORITHMS

• IMAGES VIEWED as in CT/ MRI workstations

• No. of SLICES depends on thickness of

compressed breast tissue
• Parameters such as sweep angle, No. of projections and acquisition
parameters – FIXED FOR VENDORS
• Not exactly a 3D technique
?? 3rd dimension from planar data > Some possibility
of missing lesions if out of plane

• VIEWS: CC, MLO, ML

• Normal one view in DM and other in DBT

( To reduce patient radiation exposure + detect
MICROCALCIFICATIONS)
 Synthetic Mammography (SM)
• 2D image from DBT data set
• WHY?
- To reduce the radiation dosage from traditional DM+ DBT
technique
Advantages Of DBT Supplementation
1. Better Evaluation of Masses, architectural distortions and
asymmetries
- DBT comparable to MRI in detecting size of mass, with incr.
sensitivity than FFDM
- Inc. sensitivity in margin discrimination and suspicious margin
characteristics like spiculations & microlobulations
 FAT NECROSIS

- Can show fat within masses

like Fat necrosis, lipomas,
galactoceles and hamartomas
due to thin stacks

- Inc. detection rate of benign

differentials like radial scars or
complex sclerosing lesions
- Better detection of skin
calcifications, tortuous vessels and
intramammary lymph nodes
(PSEUDOMASSES)
2. Reduces unnecessary investigations like more views, USG or MRI
3. Enables depth determination or lesion localization
- Important for targeted USG or guided biopsy
A) Improves Cancer Detection Rate (CDR):
- Oslo Tomosynthesis Screening Trial (OTST) from 6.1 to
8.0
- Screening with Tomosynthesis or Mammography trial
(STORM) from 5.3 to 8.1

- Subsequently in 2011, DBT was approved by FDA for

supplemental use with screening and diagnostic FFDM
- Improvement was seen more in the detection of
invasive cancers with relatively good prognosis
like tubular, papillary and mucinous subtypes

- Determination and delineation of multicentricity

and multifocality of malignancy are better
B) Reduced False Positive (FP) Rates:
- FP due to obscuration of margins or appearance of
pseudo-masses
- DBT makes malignant masses appear more malignant
and benign masses to be more benign
- The OTST trial reported reduced false-positive rates
from 6.1 to 5.3% comparing FFDM vs. DBT-FFDM
- The estimated reduction in false-positive rate in the
STORM trial was by 17% when using DBT-FFDM
C) Reduction in Recall Rates (RR):
-A multitude of suspicious abnormalities seen on 2D
mammography need further characterization with USG or
MRI
- Reduction upto 5.5% in RR along with increase in
positive predictive value (PPV) of the recalls by
approximately 5% are reported
 Limitations and Disadvantages
1. Radiation dose and DBT
- Mean Glandular Dose (MGD) to
the breast is higher in DBT than in
FFDM
- Addition of 2 tomosynthesis view
to the 2D mammogram increases the
radiation dose to X 2

- However, it is still below the 3

mGy/ view limit set by FDA
2. Calcifications
- Not reliable to
characterize or detect
microcalcifications.
- FFDM with spot
magnification (SM)
views is the standard
- The emerging role
of SM+ DBT vs.
FFDM+DBT is being
evaluated.
3.Storage:
- DBT files are much larger than 2D FFDM or
even CT or MRI files, about 200–450 MB
compared to 8–24 MB size of a FFDM file
- Even higher with SM

4. Longer acquisition times

5. Longer Reading time
 Current Screening Guidelines
• Considered to be optional in screening guidelines >
insufficient data supporting improvement in disease-specific
mortality.
• The National Comprehensive Cancer Network (NCCN)
guidelines recommends,
To be considered at annual screening mammography in
1. women of average risk for cancer
beginning at the age of 40
2. high-risk women starting at the age of 30
years
THANK YOU