Table Of ContentBREAST
TOMOSYNTHESIS
Liane E. Philpotts, MD, FACR
Professor
Chief of Breast Imaging
Department of Radiology and Biomedical Imaging
Yale School of Medicine
New Haven, Connecticut
Regina J. Hooley, MD
Associate Professor
Vice Chair for Clinical Affairs
Department of Radiology and Biomedical Imaging
Yale School of Medicine
New Haven, Connecticut
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
BREAST TOMOSYNTHESIS ISBN: 978-0-323-35827-9
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Library of Congress Cataloging-in-Publication Data
Names: Philpotts, Liane E., author. | Hooley, Regina J., author.
Title: Breast tomosynthesis / [edited by] Liane E. Philpotts, Regina J.
Hooley.
Description: Philadelphia, PA : Elsevier, [2017] | Includes bibliographical
references.
Identifiers: LCCN 2016046250 | ISBN 9780323358279 (pbk. : alk. paper)
Subjects: | MESH: Mammography | Imaging, Three-Dimensional | Breast
Neoplasms--radiography
Classification: LCC RG493.5.R33 | NLM WP 815 | DDC 618.1/907572--dc23
LC record available at https://lccn.loc.gov/2016046250
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Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated to our families
Grant, Paisley, Cameron, and Bryce Thomson
and
Alex, Miles, Nate, Elliot, and Josh Metviner
For your love, support, and encouragement
Contributors
Amanda Albarella, AS, RT(R)(M)(BS) Paul H. Levesque, MD
Mammography Technologist/Breast Sonographer Assistant Professor of Diagnostic Radiology
Breast Imaging Department of Radiology and Biomedical Imaging
Yale-New Haven Hospital Yale School of Medicine
New Haven, Connecticut New Haven, Connecticut
Liva Andrejeva, MD Renee Morgan, RT (R)(M)
Assistant Professor Clinical Research Coordinator
Department of Radiology and Biomedical Imaging Elizabeth Wende Breast Care, LLC
Yale School of Medicine Rochester, New York
New Haven, Connecticut
Loren Niklason, PhD
Andrea Arieno, BS
Tetonia, Idaho
Clinical Research Coordinator
Liane E. Philpotts, MD, FACR
Elizabeth Wende Breast Care, LLC
Rochester, New York Professor
Chief of Breast Imaging
Reni Butler, MD
Department of Radiology and Biomedical Imaging
Assistant Professor Yale School of Medicine
Department of Radiology and Biomedical Imaging New Haven, Connecticut
Yale School of Medicine
Madhavi Raghu, MD
New Haven, Connecticut
Assistant Professor
Stamatia Destounis, MD, FACR, FSBI
Department of Radiology and Biomedical Imaging
Radiologist Yale School of Medicine
Elizabeth Wende Breast Care, LLC New Haven, Connecticut
Rochester, New York
Laura Sheiman, MD
Melissa Durand, MD
Assistant Professor
Assistant Professor Department of Radiology and Biomedical Imaging
Department of Radiology and Biomedical Imaging Yale School of Medicine
Yale School of Medicine New Haven, Connecticut
New Haven, Connecticut
Jules H. Sumkin, DO, FACR, FSBI
Jaime Geisel, MD
Professor and Chair
Assistant Professor Department of Radiology
Department of Radiology and Biomedical Imaging University of Pittsburgh Medical Center
Yale School of Medicine UPMC Endowed Chair for Women’s Imaging
New Haven, Connecticut Pittsburgh, Pennsylvania
Regina J. Hooley, MD Ernestine Thomas, MD
Associate Professor Breast Imaging
Vice Chair for Clinical Affairs University of Pittsburgh Medical Center, Hamot
Department of Radiology and Biomedical Imaging Erie, Pennsylvania
Yale School of Medicine
Margarita Zuley, MD, FACR
New Haven, Connecticut
Vice Chair
Laura J. Horvath, MD
Quality Assurance and Strategic Development
Assistant Professor Professor of Radiology
Department of Radiology and Biomedical Imaging University of Pittsburgh Medical Center
Yale School of Medicine Pittsburgh, Pennsylvania
New Haven, Connecticut
vi
Foreword
I very much appreciated Drs. Liane Philpotts and Regina not substantially improve cancer detection, the development of
Hooley asking me to write the Foreword to their excellent digital detectors paved the way for a major advance in x-ray
book, Breast Tomosynthesis. They have had considerable experi- mammography—DBT.
ence using digital breast tomosynthesis (DBT) and have put After becoming the Head of the Breast Imaging Division at
together a clear, concise text that covers all the important issues Massachusetts General Hospital (MGH) in 1978, I recognized
surrounding tomosynthesis applied to the breast, the introduc- what was obvious to all radiologists reading mammograms—the
tion of its use to clinical care, and the issues involved in replac- superimposition of normal tissue of the breast often blocked the
ing two-dimensional (2D) mammography with DBT as the visibility of breast cancers. I was struck by the obvious improved
next advance in breast cancer screening. This will be the go-to clarity with which lesions were seen on specimen radiographs
work for those who want to improve their ability to detect more after they had been surgically removed from the breast. My goal
cancers at a curable size and stage and further decrease deaths was to find ways to image cancers with similar clarity while they
from these cancers. were still in the breast.
Mammography screening, which began in the United States I was trained in the era of linear and polycycloidal tomogra-
in the mid-1980s, has been one of the major medical advances phy, when you could blur the planes above and below the plane
in women’s health in the last 50 years. Before the introduc- of interest by moving the x-ray tube and film holder in opposite
tion of mammography screening, the breast cancer death rate directions during a prolonged exposure. This worked well, for
in the United States had remained unchanged dating back to example with renal imaging, but it required a full dose expo-
1940. However, in 1990, breast cancer deaths suddenly began to sure for each plane. In 1976 Bailar6 had (incorrectly) written
decline, and as more women participate in screening, the death that radiation from mammography would cause more cancers
rate continues to fall. There are now 35% fewer deaths each than would be cured, so there was great concern about mam-
year from breast cancer, in large part due to screening. Therapy mography and any x-ray exposure to the breast. Conventional
has improved, but in numerous observational analyses,1-4 the tomography exposed the breast to far too much dose, so it was
decline in death rates among women who participate in screen- not a viable approach to breast evaluation. Although Chang and
ing is much greater than it is among those who do not. colleagues7 made an important observation that breast cancers
In the United States, 40,000 women still die each year from were enhanced on computed tomography (CT) scans following
breast cancer. In a study that my colleagues and I conducted in the intravenous administration of iodinated contrast, CT was
two of the Harvard teaching hospitals,5 we found that more than still in its early development. CT required iodinated contrast,
70% of the women who died from breast cancer were among its spatial resolution was insufficient, and the dose was too high.
the 20% of women who were not participating in screening, and Although a dedicated breast CT scanner had been built, the
it is likely that many of the 40,000 annual deaths from breast approach was dropped.
cancer are among women who were not being screened. Mam- In 1978, while reading a series of old papers, I came across
mography has been an important tool in the fight against breast one by Miller and coworkers8 that used the term tomosynthesis to
cancer, but we know that it is far from perfect and that it does describe the process of collecting a few projection images from
not find every cancer early enough to permit a cure. multiple angles and utilizing them to synthesize an “infinite”
Although detractors of screening have claimed that mam- number of planes through the structure being imaged. I became
mography is an old and outdated technology, this could not be immediately convinced that tomosynthesis was the solution
further from the truth. Once screening was shown to save lives, that I was looking for and that it could be a major improvement
radiologists did not rest, and there have been significant advances in finding breast cancers. Development was far more difficult
in breast cancer detection over the decades. The plain film, than you might expect. It has been almost 50 years since I first
high-dose technique of the 1960s, used in the first randomized decided to apply tomosynthesis to breast cancer screening.
controlled trial of screening, was replaced by xeroradiography, It was clear to me that tomosynthesis for breast evaluation
leading to a major improvement in cancer detection at a lower might allow us to detect cancers that were hidden by normal
dose of radiation. In an effort to further reduce dose, film-screen breast tissue. Unfortunately, my MGH colleagues and I needed
combinations were developed and improved over time. Digital digital images, and the kind of detector this required did not
radiography was introduced for other organ systems under the become available for digital breast imaging until 1992.
U.S Food and Drug Administration (FDA) 510K process, but In that year, Rick Moore, my research director at MGH,
because of politics, digital mammography was delayed by the Loren Niklason, PhD, who had become our division physicist
FDA, which required companies to pursue a more arduous and in 1992, and I joined the Digital Mammography Develop-
expensive premarket approval process. Full-field digital mam- ment Group (later to become the International Digital Mam-
mography (FFDM) was only slightly better than film-screen mography Development Group [DMDG]). DMDG had been
combinations in detecting cancers, but because of the logistical organized by Etta Pisano, MD, and consisted of Etta’s group;
advantages of digital, it has almost completely replaced film- my group at MGH; Stephen Feig, MD, from Thomas Jefferson
screen mammography. Although digital mammography did University; Martin Yaffe, PhD; and Donald Plewes, PhD, from
vii
viii Foreword
Sunnybrook Hospital (Toronto, Canada), the Fisher Imaging Although the detection and removal of DCIS is probably the
company, and General Electric (GE). The goal of the DMDG reason the rate of invasive cancers is lower than expected, there
was to aid companies in developing FFDM. I informed Rick are real concerns about detecting too many lesions that might
and Loren that I wanted to apply the concept of tomosynthesis never progress to invasive and lethal cancers. Mammography
to the breast, and I gave them the article that I had on the topic. has been faulted because it is the main reason these lesions are
They advised me that GE had the detector that could do what I now detected. However, DBT does not increase the detection of
wanted, so we partnered with GE in the DMDG to gain access DCIS. The reason is that most DCIS is found by detecting clus-
to their detector. Once we had the GE detector, we found that by tered microcalcifications. Although Kopans and colleagues16
moving the x-ray tube by hand over phantoms and mastectomy showed several years ago that DBT characterizes calcifications
specimens, we could successfully perform tomosynthesis of the more clearly than does 2D mammography, their very high con-
breast. The physics had been worked out by Loren and two other trast means that DBT does not increase our ability to detect
physicists, and we applied for and obtained a patent in 1999. them. They are found fairly easily using 2D mammography.
We also applied for and received a grant from the Depart- Consequently, although DBT detects more small (curable)
ment of Defense and paid GE to build the first tomosynthesis invasive cancers, it does not increase the detection of DCIS.
system that could image the entire breast. When no one stepped There is no question that having to review multiple planes
up to name the new approach in a contest that I held at MGH, for each screening case increases the time it takes to interpret
I named it digital breast tomosynthesis because I felt that the screening studies, but DBT saves time by reducing recalls. In
acronym DBT was easy to say and remember. my experience, once radiologists use DBT, they are not inter-
Although MGH licensed the technology to GE, I thought ested in returning to only 2D mammography.
that it was important to move it forward as quickly as possible The initial FDA approval for DBT required a full exposure
for the benefit of women, so we worked with any company set of 2D screening images to accompany the DBT images.
that was interested in our technology. Having convinced both Many years ago Rick Moore at MGH was the first to put the
Hologic and Siemens of the importance of the technology, we planes back together to form a synthetic 2D “slab.” This has now
helped them develop their systems. It is both remarkable and led to a full synthesis of the 2D mediolateral oblique and cra-
unfortunate how long it took to move this technology from a niocaudal images from the DBT acquisition images. Although
prototype to a commercial device. However, DBT is now avail- there is probably no risk from radiation to the breasts of women
able, and this book provides excellent discussions of its benefits ages 40 years and older, the use of synthetic 2D mammography
and clear examples and explanations of its use. eliminates that extra dose, which was previously required.
It has been interesting to watch the introduction of DBT Breast Tomosynthesis is an excellent guide for those seeking
into clinical practice. Although we developed DBT as a screen- to adopt and use DBT for the first time, as well as for the expe-
ing test, it has undergone a stepwise introduction to finally rienced radiologist. Virtually every aspect of its use is covered
reach that point. As Breast Tomosynthesis clearly shows and as in clear detail. I have no doubt that radiologists will embrace
we recognized early in its development, DBT is the next step this important advancement in the quest to improve women’s
in improving screening for breast cancer. DBT increases the health. I expect ultrasound to be added to the DBT systems
detection of small invasive cancers while reducing the recall to permit the simultaneous acquisition of ultrasound and DBT,
rate according to most of the published studies.9-15 The former which will facilitate the detection of the small percentage of
is not surprising because small cancers are the most likely to cancers that are not visible on DBT but can be found by ultra-
be hidden on 2D mammography. However, usually when you sound. We have looked at using DBT to inform on electrical
increase the sensitivity (detection rate) of a test, you have to impedance measurements, as well as optical imaging. I expect
lower your thresholds for intervention and you find more of that DBT, with its quasi-3D information, will become the plat-
everything, increasing the false positive rate. DBT is an excep- form on which other technologies are added to help us detect
tion to this, making it a win-win technology. It detects more more cancers at a time when cure is possible. Thanks to all the
cancers (improved sensitivity) while reducing the recall rate contributors to this excellent book.
(improved specificity). In our practice, 25% of recalls from
screening with 2D mammography proved to be nothing more Daniel B. Kopans, MD, FACR
than superimposed normal tissues, called summation shadows by Professor of Radiology, Harvard Medical School
Sickles. DBT eliminates these summation shadows, which is Senior Radiologist, Breast Imaging Division
one of the main reasons recall rates have been diminishing. Department of Radiology, Massachusetts General Hospital
One final point. There are legitimate questions about Avon Comprehensive Breast Evaluation Center
the importance of finding ductal carcinoma in situ (DCIS). Boston, Massachusetts
Foreword ix
References
9. Skaane P, Gullien R, Bjørndal H, et al. Digital breast tomosynthesis (DBT):
initial experience in a clinical setting. Acta Radiol. 2012;53(5):524–529.
1. Swedish Organised Service Screening Evaluation Group. Reduction in 10. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammogra-
breast cancer mortality from organized service screening with mammogra- phy alone and digital mammography plus tomosynthesis in a population-
phy: 1. Further confirmation with extended data. Cancer Epidemiol Biomark- based screening program. Radiology. 2013;267:47–56.
ers Prev. 2006;15:45–51. 11. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mam-
2. Otto SJ, Fracheboud J, Looman CWN, et al. Initiation of population-based mography with tomosynthesis for population breast-cancer screening
mammography screening in Dutch municipalities and effect on breast- (STORM): a prospective comparison study. Lancet Oncol. 2013;14:583–589.
cancer mortality: a systematic review. Lancet. 2003;361:411–417. 12. Lång K, Andersson I, Rosso A, et al. Performance of one-view breast
3. Hellquist BN, Duffy SW, Abdsaleh S, et al. Effectiveness of population- tomosynthesis as a stand-alone breast cancer screening modality: results
based service screening with mammography for women ages 40 to 49 years: from the Malmö Breast Tomosynthesis Screening Trial, a population-based
evaluation of the Swedish Mammography Screening in Young Women study. Eur Radiol. 2015 May 1. [Epub ahead of print]
(SCRY) cohort. Cancer. 2011;117(4):714–722. 13. Haas BM, Kalra V, Geisel J, et al. Comparison of tomosynthesis plus digital
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mography screening and mortality from breast cancer. J Natl Cancer Inst. Radiology. 2013;269(3):694–700.
2014;106(11). 14. Rose SL, Tidwell AL, Bujnoch LJ, et al. Implementation of breast tomo-
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6. Bailar JC. Mammography: a contrary view. Ann Intern Med. 1976;84:77–84. ing tomosynthesis in combination with digital mammography. JAMA.
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Preface
Tomosynthesis has revolutionized mammography. We are We are extremely grateful to our colleagues at Yale who share
grateful to all the individuals who had the incredible vision and our vision of the value of tomosynthesis. In particular, we would
drive to develop this amazing mammography technology. Our like to thank those individuals who were instrumental in sup-
practice was fortunate enough to be involved with tomosynthe- porting our early adoption of this new technology, specifically
sis from an early stage—being one of the initial beta sites for Jim Brink, MD; TR Goodman, MD; Cheryl Granucci; and
development and one of the first clinical sites after approval by Jacqueline Crenshaw. Our clinical work could not have been
the U.S. Food and Drug Administration. Because we work with achieved without our dedicated hard-working and professional
many talented breast imaging colleagues, we had the special staff, including Sherry Delaventura, Fran Fanelli, Maria Gum-
opportunity to review challenging cases, ask each other ques- kowski, Rhona Hall, Nicole Perez, Christine Puciato, Juliette
tions, and learn together. Buccilli, and all of the many skilled breast imaging technologists
Tomosynthesis is truly a game changer, but at the same of Yale-New Haven Hospital. Working together using tomo-
time, it has dramatically altered the practice of breast imaging. synthesis provides our patients with much better outcomes.
There is a learning curve when it comes to reading tomosyn- We are very thankful for the patience and support of our
thesis studies. In addition, many of the conventional mam- team at Elsevier, who guided us through this process, particu-
mographic work-up techniques are no longer relevant. We larly Robin Carter, Janice Gaillard, Doug Turner, Nicole Beard,
felt that our experiences with this new technology and the Catherine Jackson, and a host of others. Importantly, this book
knowledge that we gained as a result could prove quite valu- would not have been possible without the support and encour-
able to other breast imaging specialist. That is why we wrote agement of our husbands and children, who thankfully spared
this book. us the time to pursue our passion. Finally, we are indebted to
Writing a textbook about a three-dimensional (3D) imag- our patients who have entrusted our service to perform and
ing technology was, to say the least, a challenge! A textbook interpret their mammograms year after year and have given us a
can only use two-dimensional images. We have tried to cap- precious gift—an invaluable source of information that we can
ture single slice tomosynthesis images that best depict a variety now share so many others may also benefit.
of findings. Additional 3D content, which better depicts the
tomosynthesis findings encountered in clinical practice, is avail- Liane E. Philpotts, MD
able on the web-based version. Regina J. Hooley, MD
x
1 Introduc1 tion,
LiaEne.P hilpoItR tesg iJn.Ha o oley
2 PhysaincdsD evelopomfeB nrte aTsotm osynth5e sis,
LoreNni klason
3 ThTee chnoloPgeirsstp'esc 9t ive,
RegiJn.Ha o oleIAy m andAal bareIlL liaa nE.eP hilpotts
4 ImplementoafDt iigoinBt raela stTomosyInnttChole isniiPscr aalc t1i8c e,
StamaDteisat ouInA insd rAerai enIRo e neMeo rgaInL ianEe.P hpiolt ts
5 TomosyntihneS scirse enMianmgm ograp2h6y ,
MelisDsuara nIdL ianEe.P hilpotts
6 TomosyntihneD siiasg noMsatmimco grap3h9y ,
RenBiu tlIeRr e giJn.Ha o oley
7 TomosynthIenstiesr pretaatnidPo int fTai5lp6ls s ,
LianeP hEi.l poItR tesg iJnH.a o oley
8 BeniFginn din74g s,
LaurSah eimIaLn i aEn.eP hilpotts
9 Malignant F8i8n dings,
PauHl.L evesqIuR ee giJnH.ao oley
10 Architectural1 0D0i stortion,
MadhaRvaig hIuR egiJnH.ao oley
11 IntegrTaotmionsgy ntWhietsMhiu sl timodIamlaigtiy1n 1g5,
LivAan drejIeJv aai mGee isIeLl i anEe.P hilpotts
12 TheP ostoperBarteiavs1et3 3,
LaurJa.H orvaItL hi anEe.P hilpotts
13T omosyntihnet shieMs a lBer eas1t5,2
LianEe.P hilpotts
14 IntervenPtrioocneadlu1 r6e7s ,
MargarZiutlaeI yE rnesTthionmea IsJ ulHe.sS umkiInR enBiu tler
VideCoa sSet udi1e8s1,
SelecRteeadd in2g4s3,
xi
