Original InvestigationSynthesized Mammography: The New Standard of Care When Screening for Breast Cancer with Digital Breast Tomosynthesis?
Introduction
Digital breast tomosynthesis (DBT) is a relatively recent advancement in breast imaging that decreases recall rate and improves invasive cancer detection rate (CDR) 1, 2, 3, 4, 5, 6. The US Food and Drug Administration (FDA) initially approved DBT as a screening adjunct to be used in combination with standard full-field digital mammography (FFDM). The primary reasons that DBT was only approved in combination with FFDM were that some findings, such as microcalcifications, are thought to not be well visualized on DBT 7, 8, and the standard FFDM examination allows easier comparison to previous examinations.
The disadvantage of combination FFDM and DBT is an approximate twofold increase in radiation dose (9), although the total dose still falls within radiation dose limits set forth by the Mammographic Quality and Standards Act (3 mGy). Concerns regarding increased radiation dose led to the advancement of synthesized two-dimensional mammography (SM). SM is a technique that generates two-dimensional images from the DBT dataset, eliminating the need for a separately acquired FFDM examination and thereby decreasing the radiation dose to the patient (10). The FDA approved replacing FFDM with a specific SM technique (Selenia Dimensions 3D System with C-View Software Module, sponsored by Hologic, Inc., Marlborough, MA) for screening mammography in May 2013.
There have been limited studies comparing SM + DBT to FFDM + DBT. In 2009, one small study using a first version of SM + DBT demonstrated lower sensitivity and similar specificity compared to FFDM + DBT (11). Since then, a few reader studies and prospective studies have shown overall comparable results between the two techniques 12, 13, 14. For example, in 2014, Zuley et al. published a retrospective observer performance study of 123 cases concluding that SM was comparable in performance to FFDM. Recently, the first study was published evaluating implementation of SM + DBT in a screening population compared to historic screening outcomes of FFDM + DBT (15). Results showed decreased recall rate and radiation dose in the SM + DBT group while maintaining CDR. The purpose of this study was to further validate the use of SM in women being screened with DBT by comparing the performance metrics of SM + DBT to FFDM + DBT in screening asymptomatic women at a large multisite academic center.
Section snippets
Materials and Methods
This was an Health Insurance Portability and Accountability Act compliant, institutional review board approved study with a waiver of informed consent. We retrospectively evaluated outcome metrics of two cohorts of patients undergoing breast cancer screening with DBT at multiple sites of a single institution. The first cohort included patients screened with DBT and FFDM from April 1, 2013, to February 14, 2015 (n = 7845) and the second included patients screened with DBT and SM from February
Results
A total of 7845 asymptomatic women underwent screening with FFDM + DBT between April 4, 2013, and February 14, 2015, and a total of 14,776 asymptomatic women underwent screening with SM + DBT between February 15, 2015, and February 15, 2016. After excluding screening recalls for technical issues (n = 32 in the FFDM + DBT group and n = 54 in the SM + DBT group), a total of 7813 studies were included in the first cohort and 14,722 in the second cohort. From recall recommendation, 2 patients were
Discussion
Breast cancer screening with combined FFMD + DBT decreases recall rate and improves CDR 1, 2, 3, 4, 5, 6 but also increases radiation dose (9). In this study, we found that replacing FFDM with SM in an asymptomatic population being screened with DBT does not affect biopsy rate, PPV1, PPV3, or CDR, and decreased recall rate.
We found similar biopsy rates, PPV1, PPV3, and CDR between the cohort screened with FFDM + DBT and the cohort screened with SM + DBT. This supports a previous study, which
Acknowledgments
The authors have no disclosures of possible conflict of interest and/or commercial involvement. The authors are grateful for the support of Jennifer Kline in data acquisition.
References (18)
- et al.
Breast cancer screening with tomosynthesis (3D mammography) with acquired or synthetic 2D mammography compared with 2D mammography alone (STORM-2): a population-based prospective study
Lancet Oncol
(2016) - et al.
Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study
Lancet Oncol
(2013) - et al.
Dose reduction in digital breast tomosynthesis (DBT) screening using synthetically reconstructed projection images: an observer performance study
Acad Radiol
(2012) - et al.
Review of radiation dose estimates in digital breast tomosynthesis relative to those in two-view full-field digital mammography
Breast
(2015) - et al.
Assessing radiologist performance using combined digital mammography and breast tomosynthesis compared with digital mammography alone: results of a multicenter, multireader trial
Radiology
(2013) - et al.
Diagnostic accuracy and recall rates for digital mammography and digital mammography combined with one-view and two-view tomosynthesis: results of an enriched reader study
AJR Am J Roentgenol
(2014) - et al.
Screening outcomes following implementation of digital breast tomosynthesis in a general-population screening program
J Natl Cancer Inst
(2014) - et al.
Prospective trial comparing full-field digital mammography (FFDM) versus combined FFDM and tomosynthesis in a population-based screening programme using independent double reading with arbitration
Eur Radiol
(2013) - et al.
Detection and classification of calcifications on digital breast tomosynthesis and 2D digital mammography: a comparison
AJR Am J Roentgenol
(2011)
Cited by (13)
Prospective Comparison of Synthesized Mammography with DBT and Full-Field Digital Mammography with DBT Uncovers Recall Disagreements That may Impact Cancer Detection
2022, Academic RadiologyCitation Excerpt :Mammography follow-up detected five new breast cancers (1 IDC, 2 IDC+DCIS, 1 ILC, 1 DCIS) in five patients: one patient at 8 months (imaging prompted by new bloody nipple discharge and palpable mass) and four patients at 11–15 months postinitial screening (early or late for annual screening), in whom prior SM+DBT or FFDM+DBT interpretations prompted no recall. Our study demonstrated no statistical difference in RR, PPV1, and CDR, similar to multiple other studies (8,9,12–24). A few prospective studies comparing the performance of SM+DBT and FFDM+DBT had mixed results: some showing similar performance, while others showed lower sensitivity for SM+DBT than for FFDM+DBT but comparable specificity for the two imaging modalities (8,13,22).
Breast cancer screening using synthesized two-dimensional mammography: A systematic review and meta-analysis
2021, BreastCitation Excerpt :Due to that the SM image is created from the DBT dataset, vendor differences in DBT acquisition result in vendor-specific DBT images and subsequently varying synthesized results [15]. Most studies used Hologic Selenia Dimensions with improved version of the reconstructed synthesized image processing software (C-View) [28,30,33,38–41]. In addition, the radiologists in the RCT had insufficient experience in screen reading of DBT, so the radiologists may have not yet achieved optimal screen reading capabilities with DBT at the startup of the study [19].
The threshold detectable mass diameter for 2D-mammography and digital breast tomosynthesis
2019, Physica MedicaCitation Excerpt :A potential solution may lie in the use of synthetic imaging, which provides the generation of a synthesised 2D image from DBT data (and thus eliminating the use of 2D-mammography), and is available from some manufacturers. There are on-going studies on the use of synthetic imaging in screening [40–43] and the identification of its strengths and weaknesses [44]. This study also provided a comparison between an existing narrow angle DBT and a wide angle DBT system when the same image receptor and X-ray spectrum are used.
Insights into innovative breast imaging techniques
2019, Clinical ImagingDigital breast tomosynthesis: Image acquisition principles and artifacts
2019, Clinical Imaging