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Machaon M Bonafede,1 Vivek B Kalra,2 Jeffrey D Miller,1 Laurie L Fajardo3 1Truven Health Analytics, Cambridge, MA, 2Yale University School of Medicine, New Haven, CT, 3Department of Radiology, University of Iowa College of Medicine, Iowa City, IA, USA Purpose: The objective of this study was to conduct a value analysis of digital breast tomosynthesis (DBT) for breast cancer screening among women enrolled in US commercial health insurance plans to assess the potential budget impact associated with the clinical benefits of DBT. Methods: An economic model was developed to estimate the system-wide financial impact of DBT as a breast cancer screening modality within a hypothetical US managed care plan with one million members. Two scenarios were considered for women in the health plan who undergo annual screening mammography, ie, full field digital mammography (FFDM) and combined FFDM + DBT. The model focused on two main drivers of DBT value, ie, the capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic services and the capacity of DBT to facilitate earlier diagnosis of cancer at less invasive stages where treatment costs are lower. Model inputs were derived from published sources and from analyses of the Truven Health MarketScan® Research Databases (2010–2012). Comparative clinical and economic outcomes were simulated for one year following screening and compared on an incremental basis. Results: Base-case analysis results show that 4,523 women in the hypothetical million member health plan who are screened using DBT avoid the use of follow-up services. The overall benefit of DBT was calculated at $78.53 per woman screened. Adjusting for a hypothetical $50 incremental cost of the DBT examination, this translates to $28.53 savings per woman screened, or $0.20 savings per member per month across the plan population and an overall cost savings to the plan of $2.4 million per year. Conclusion: The results of this study demonstrate clinical and economic favorability of DBT for breast cancer screening among commercially-insured US women. Wider adoption of DBT mammography presents an opportunity to deliver value-based care in the US health care system. Keywords: breast cancer screening, mammography, digital breast tomosynthesis, cost analysis, value analysis, economic model

A national task force consisting of members from the American College of Radiology, the American College of Surgeons, and the College of American Pathologists examined the issues surrounding stereotactic core-needle biopsy for occult breast lesions. Their report includes indications and contraindications, informed consent, specimen handling, and management of indeterminate, atypical, or discordant lesions. [ABSTRACT FROM AUTHOR]

Background: Film mammography has limited sensitivity for the detection of breast cancer in women with radiographically dense breasts. We assessed whether the use of digital mammography would avoid some of these limitations. Methods: A total of 49,528 asymptomatic women presenting for screening mammography at 33 sites in the United States and Canada underwent both digital and film mammography. All relevant information was available for 42,760 of these women (86.3 percent). Mammograms were interpreted independently by two radiologists. Breast-cancer status was ascertained on the basis of a breast biopsy done within 15 months after study entry or a follow-up mammogram obtained at least 10 months after study entry. Receiver-operating-characteristic (ROC) analysis was used to evaluate the results. Results: In the entire population, the diagnostic accuracy of digital and film mammography was similar (difference between methods in the area under the ROC curve, 0.03; 95 percent confidence interval, -0.02 to 0.08; P=0.18). However, the accuracy of digital mammography was significantly higher than that of film mammography among women under the age of 50 years (difference in the area under the curve, 0.15; 95 percent confidence interval, 0.05 to 0.25; P=0.002), women with heterogeneously dense or extremely dense breasts on mammography (difference, 0.11; 95 percent confidence interval, 0.04 to 0.18; P=0.003), and premenopausal or perimenopausal women (difference, 0.15; 95 percent confidence interval, 0.05 to 0.24; P=0.002). Conclusions: The overall diagnostic accuracy of digital and film mammography as a means of screening for breast cancer is similar, but digital mammography is more accurate in women under the age of 50 years, women with radiographically dense breasts, and premenopausal or perimenopausal women. (ClinicalTrials.gov number, NCT00008346.) [ABSTRACT FROM AUTHOR]

Contrast-enhanced mammography (CEM) is an emerging breast imaging technology with promise for breast cancer screening, diagnosis, and procedural guidance. However, best uses of CEM in comparison with other breast imaging modalities such as tomosynthesis, ultrasound, and MRI remain inconclusive in many clinical settings. This review article summarizes recent peer-reviewed literature, emphasizing retrospective reviews, prospective clinical trials, and meta-analyses published from 2020 to 2023. The intent of this article is to supplement prior comprehensive reviews and summarize the current state-of-the-art of CEM., (© The Author(s) 2024. Published by Oxford University Press on behalf of the British Institute of Radiology.)

Background A new modality, phase-sensitive breast tomosynthesis (PBT), may have similar diagnostic performance to conventional breast tomosynthesis but with a reduced radiation dose. Purpose To perform a pilot study of the performance of a novel PBT system compared with conventional digital breast tomosynthesis (DBT) in patients undergoing additional diagnostic imaging workup for breast lesions. Materials and Methods In a prospective study from June 2020 to March 2021, participants with suspicious breast lesions detected at screening DBT or MRI were recruited for additional PBT imaging before additional diagnostic workup or biopsy. In this pilot study, nine radiologists independently evaluated image quality and assessed the likelihood of lesion malignancy by retrospectively evaluating DBT and PBT images in two separate reading sessions. Image quality was rated subjectively using a Likert scale from 1 to 5. Areas under the receiver operating characteristic curve (AUCs) were used to compare the lesion classification (malignant vs benign) performance of the radiologists. Results Images in 50 patients (mean age, 56 years ± 12 [SD]; 49 women) with 52 evaluable lesions (28 malignant) were assessed. For image appearance and general feature visibility, DBT images had a higher total mean image quality score (3.8) than PBT images (2.9), with P < .002 for each comparison. For classification of lesions as benign or malignant, the AUCs were 0.74 for both PBT and DBT. PBT images were acquired at a 24% mean radiation dose reduction (mean, 1.78 mGy vs 2.34 mGy for DBT; P < .001). Conclusion The phase-sensitive breast tomosynthesis system had a 24% lower mean radiation dose compared with digital breast tomosynthesis, although with lower image quality. Diagnostic performance of the system remains to be determined in larger studies. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Gao and Moy in this issue.

Autologous fat grafting (AFG) is a technique that is increasingly utilized in breast cosmetic and reconstructive surgery. In this procedure, fat is aspirated by liposuction from one area of the body and injected into the breast. The procedure and process of AFG has evolved over the last few decades, leading to more widespread use, though there is no standard method. Autologous fat grafting is generally considered a safe procedure but may result in higher utilization of diagnostic imaging due to development of palpable lumps related to fat necrosis. Imaging findings depend on surgical technique but typically include bilateral, symmetric, retromammary oil cysts and scattered dystrophic and/or coarse calcifications when AFG is used for primary breast augmentation. More focal findings occur when AFG is used to improve specific areas of cosmetic deformity, scarring, or pain following breast cancer surgery. As with any cause of fat necrosis, imaging features tend to appear more benign over time, with development of rim calcifications associated with oil cysts and a shift in echogenicity of oil cyst contents on ultrasound towards anechoic in some cases. This article reviews the AFG procedure, uses, complications, and imaging findings., (© Society of Breast Imaging 2021. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

The Radiology Research Alliance (RRA) of the Association of University Radiologists (AUR) convenes Task Forces to address current topics in radiology. In this article, the AUR-RRA Task Force on Academic-Industry Partnerships for Artificial Intelligence, considered issues of importance to academic radiology departments contemplating industry partnerships in artificial intelligence (AI) development, testing and evaluation. Our goal was to create a framework encompassing the domains of clinical, technical, regulatory, legal and financial considerations that impact the arrangement and success of such partnerships., (Copyright © 2021 The Association of University Radiologists. All rights reserved.)

Purpose: To compare imaging performance of a cadmium telluride (CdTe) based photon counting detector (PCD) with a CMOS based energy integrating detector (EID) for potential phase sensitive imaging of breast cancer., Methods: A high energy inline phase sensitive imaging prototype consisting of a microfocus X-ray source with geometric magnification of 2 was employed. The pixel pitch of the PCD was 55μm, while 50μm for EID. The spatial resolution was quantitatively and qualitatively assessed through modulation transfer function (MTF) and bar pattern images. The edge enhancement visibility was assessed by measuring edge enhancement index (EEI) using the acrylic edge acquired images. A contrast detail (CD) phantom was utilized to compare detectability of simulated tumors, while an American College of Radiology (ACR) accredited phantom for mammography was used to compare detection of simulated calcification clusters. A custom-built phantom was employed to compare detection of fibrous structures. The PCD images were acquired at equal, and 30% less mean glandular dose (MGD) levels as of EID images. Observer studies along with contrast to noise ratio (CNR) and signal to noise ratio (SNR) analyses were performed for comparison of two detection systems., Results: MTF curves and bar pattern images revealed an improvement of about 40% in the cutoff resolution with the PCD. The excellent spatial resolution offered by PCD system complemented superior detection of the diffraction fringes at boundaries of the acrylic edge and resulted in an EEI value of 3.64 as compared to 1.44 produced with EID image. At equal MGD levels (standard dose), observer studies along with CNR and SNR analyses revealed a substantial improvement of PCD acquired images in detection of simulated tumors, calcification clusters, and fibrous structures. At 30% less MGD, PCD images preserved image quality to yield equivalent (slightly better) detection as compared to the standard dose EID images., Conclusion: CdTe-based PCDs are technically feasible to image breast abnormalities (low/high contrast structures) at low radiation dose levels using the high energy inline phase sensitive imaging technique.

Phase retrieval is vital for quantitative x-ray phase contrast imaging. This work presents an iterative method to simultaneously retrieve the x-ray absorption and phase images from a single x-ray exposure. The proposed approach uses the photon-counting detectors' energy-resolving capability in providing multiple spectrally resolved phase contrast images from a single x-ray exposure. The retrieval method is derived, presented, and experimentally tested with a multi-material phantom in an inline phase contrast imaging setup. By separating the contributions of photoelectric absorption and Compton scattering to the attenuation, the authors divide the phase contrast image into two portions, the attenuation map arises from photoelectric absorption and a pseudo phase contrast image generated by electron density. This way one can apply the Phase Attenuation Dualiby (PAD) algorithm and Fresnel propagation for the iteration. The retrieval results from the experimental images show that this iterative method is fast, accurate, robust against noise, and thus yields noticeable enhancement in contrast to noise ratios.

Background: This article reports the first x-ray phase sensitive breast tomosynthesis (PBT) system that is aimed for direct translation to clinical practice for the diagnosis of breast cancer., Purpose: To report the preclinical evaluation and comparison of the newly built PBT system with a conventional digital breast tomosynthesis (DBT) system., Methods and Materials: The PBT system is developed based on a comprehensive inline phase contrast theoretical model. The system consists of a polyenergetic microfocus x-ray source and a flat panel detector mounted on an arm that is attached to a rotating gantry. It acquires nine projections over a 15° angular span in a stop-and-shoot manner. A dedicated phase retrieval algorithm is integrated with a filtered back-projection method that reconstructs tomographic slices. The American College of Radiology (ACR) accreditation phantom, a contrast detail (CD) phantom and mastectomy tissue samples were imaged at the same glandular dose levels by both the PBT and a standard of care DBT system for image quality characterizations and comparisons., Results: The PBT imaging scores with the ACR phantom are in good to excellent range and meet the quality assurance criteria set by the Mammography Quality Standard Act. The CD phantom image comparison and associated statistical analyses from two-alternative forced-choice reader studies confirm the improvement offered by the PBT system in terms of contrast resolution, spatial resolution, and conspicuity. The artifact spread function (ASF) analyses revealed a sizable lateral spread of metal artifacts in PBT slices as compared to DBT slices. Signal-to-noise ratio values for various inserts of the ACR and CD phantoms further validated the superiority of the PBT system. Mastectomy sample images acquired by the PBT system showed a superior depiction of microcalcifications vs the DBT system., Conclusion: The PBT imaging technology can be clinically employed for improving the accuracy of breast cancer screening and diagnosis., (© 2021 American Association of Physicists in Medicine.)

Objective: To determine whether there is added benefit for 3D mammography in the context of screening and diagnostic imaging, particularly relating to known prognostic characteristics, including histopathology, receptor status, and axillary lymph node involvement., Methods: An institutional review board-approved retrospective review was performed of our mammography and pathology databases from October 2012 to May 2015 to identify biopsy-proven invasive breast carcinoma detected on screening and diagnostic mammograms by 2D plus 3D (2D + 3D) imaging. Percentages of cancer detection by 2D and 3D were compared. Correlation with histopathology and lymph node status was analyzed., Results: Of 53 cancers diagnosed on 12 543 screening mammograms, 36 (67.9%) were better visualized on 3D (not visualized, equivocal, or only seen in retrospect on 2D). Of the 62 cancers diagnosed on 4090 diagnostic mammograms, 24 (38.7%) cancers were better detected on 3D. A statistically significant greater number of cancers were better detected on 3D in the screening compared to the diagnostic mammograms (67.9% vs 38.7%, P < .05). A significantly higher frequency of less aggressive tumors (grade I and grade II, positive estrogen/progesterone receptor, Her2 negative) was detected by 3D, with higher significance in the screening population. Additionally, there was a higher frequency of positive axillary lymph nodes in cancers detected by 3D in the screening group., Conclusion: Three-dimension increases invasive breast cancer detection, particularly pathologically less aggressive tumors, in both screening and diagnostic mammograms with more benefit for the screening population. Three-dimensional mammography detected more breast cancer associated with metastatic axillary lymph nodes in the screening population.

OBJECTIVE. The purpose of this study was to test the hypothesis whether two-view wide-angle digital breast tomosynthesis (DBT) can replace full-field digital mammography (FFDM) for breast cancer detection. SUBJECTS AND METHODS. In a multireader multicase study, bilateral two-view FFDM and bilateral two-view wide-angle DBT images were independently viewed for breast cancer detection in two reading sessions separated by more than 1 month. From a pool of 764 patients undergoing screening and diagnostic mammography, 330 patient-cases were selected. The endpoints were the mean ROC AUC for the reader per breast (breast level), ROC AUC per patient (subject level), noncancer recall rates, sensitivity, and specificity. RESULTS. Twenty-nine of 31 readers performed better with DBT than FFDM regardless of breast density. There was a statistically significant improvement in readers' mean diagnostic accuracy with DBT. The subject-level AUC increased from 0.765 (standard error [SE], 0.027) for FFDM to 0.835 (SE, 0.027) for DBT ( p = 0.002). Breast-level AUC increased from 0.818 (SE, 0.019) for FFDM to 0.861 (SE, 0.019) for DBT ( p = 0.011). The noncancer recall rate per patient was reduced by 19% with DBT ( p < 0.001). Masses and architectural distortions were detected more with DBT ( p < 0.001); calcifications trended lower ( p = 0.136). Accuracy for detection of invasive cancers was significantly greater with DBT ( p < 0.001). CONCLUSION. Reader performance in breast cancer detection is significantly higher with wide-angle two-view DBT independent of FFDM, verifying the robustness of DBT as a sole view. However, results of perception studies in the vision sciences support the inclusion of an overview image.

Objective: The objective of our study was to determine the ability of tomosynthesis (3D) to detect nonmalignant and malignant architectural distortion (AD) on 3D screening mammograms compared with digital mammography (2D) only and to correlate the 3D imaging features of nonmalignant and malignant AD with pathology findings., Materials and Methods: For this single-institution retrospective study, screening mammography reports from October 1, 2012, to December 1, 2016, that included AD as a finding were reviewed. Associated additional imaging studies and pathology results were also reviewed., Results: Three-dimensional mammography showed statistically significant increased detection of both nonmalignant and malignant AD compared with 2D only (0.10% [24/24,902 examinations] vs 0.01% [1/9470 examinations], p < 0.05; and 0.21% [52/24,902 examinations] vs 0.07% [7/9470 examinations], p < 0.05, respectively). Higher percentages of nonmalignant AD (16%) were occult on ultrasound compared with malignant AD (3%). The pathologic diagnoses of nonmalignant AD included radial scar (42%), sclerosing adenosis (16%), stromal or dense fibrosis (16%), and other miscellaneous benign causes (25%). Morphologically, nonmalignant AD was more likely to show symmetric or spoke-wheel spiculation appearance (58% vs 2%, p < 0.05) and central lucency (25% vs 0%, p < 0.05) than malignant AD, whereas malignant AD was more likely to show asymmetric spiculation (98% vs 42%, p < 0.05) and central mass 60% vs 0%, p < 0.05) than nonmalignant AD., Conclusion: Malignant AD and nonmalignant AD are more readily detected by 3D mammography than 2D mammography. Three-dimensional imaging features of AD can help to distinguish nonmalignant types in which symmetric or spoke-wheel spiculation with central lucency are more often seen and are more often occult on ultrasound.

This study compared the detectability of simulated tumors using a high-energy X-ray inline phase sensitive digital breast tomosynthesis (DBT) prototype and a commercial attenuation-based DBT system. Each system imaged a 5-cm thick modular breast phantom with 50-50 adipose-glandular percentage density containing contrast-detail (CD) test objects to simulate different tumor sizes. A commercial DBT system acquired 15 projection views over 15 degrees (15d-15p) was used to acquire the attenuation-based projection views and to reconstruct the conventional DBT slices. Attenuation-based projection views were acquired at 32 kV, 46 mAs with a mean glandular dose (D g ) of 1.6 mGy. For acquiring phase sensitive projection views, the prototype utilized two acquisition geometries: 11 projection views were acquired over 15 degrees (15d-11p), and 17 projection views were acquired over 16 degrees (16d-17p) at 120 kV, 5.27 mAs with 1.51 mGy under the magnification (M) of 2. A phase retrieval algorithm based on the phase-attenuation duality (PAD) was applied to each projection view, and a modified Feldkamp-Davis-Kress (FDK) algorithm was used to reconstruct the phase sensitive DBT slices. Simulated tumor margins were rated as more conspicuous and better visualized for both phase sensitive acquisition geometries versus conventional DBT imaging. The CD curves confirmed the improvement in both contrast and spatial resolutions with the phase sensitive DBT imaging. The superiority of the phase sensitive DBT imaging was further endorsed by higher contrast to noise ratio (CNR) and figure-of-merit (FOM) values. The CNR improvements provided by the phase sensitive DBT prototype were sufficient to offset the noise reduction provided by the attenuation-based DBT imaging., (Copyright © 2018 Associazione Italiana di Fisica Medica. Published by Elsevier Ltd. All rights reserved.)

The objective of this study was to demonstrate the potential benefits of using high energy x-rays in comparison with the conventional mammography imaging systems for phase sensitive imaging of breast tissues with varying glandular-adipose ratios. This study employed two modular phantoms simulating the glandular (G) and adipose (A) breast tissue composition in 50 G-50 A and 70 G-30 A percentage densities. Each phantom had a thickness of 5 cm with a contrast detail test pattern embedded in the middle. For both phantoms, the phase contrast images were acquired using a micro-focus x-ray source operated at 120 kVp and 4.5 mAs, with a magnification factor (M) of 2.5 and a detector with a 50 µm pixel pitch. The mean glandular dose delivered to the 50 G-50 A and 70 G-30 A phantom sets were 1.33 and 1.3 mGy, respectively. A phase retrieval algorithm based on the phase attenuation duality that required only a single phase contrast image was applied. Conventional low energy mammography images were acquired using GE Senographe DS and Hologic Selenia systems utilizing their automatic exposure control (AEC) settings. In addition, the automatic contrast mode (CNT) was also used for the acquisition with the GE system. The AEC mode applied higher dose settings for the 70 G-30 A phantom set. As compared to the phase contrast images, the dose levels for the AEC mode acquired images were similar while the dose levels for the CNT mode were almost double. The observer study, contrast-to-noise ratio and figure of merit comparisons indicated a large improvement with the phase retrieved images in comparison to the AEC mode images acquired with the clinical systems for both density levels. As the glandular composition increased, the detectability of smaller discs decreased with the clinical systems, particularly with the GE system, even at higher dose settings. As compared to the CNT mode (double dose) images, the observer study also indicated that the phase retrieved images provided similar or improved detection for all disc sizes except for the disk diameters of 2 mm and 1 mm for the 50 G-50 A phantom and 3 mm and 0.5 mm for the 70 G-30 A phantom. This study demonstrated the potential of utilizing a high energy phase sensitive x-ray imaging system to improve lesion detection and reduce radiation dose when imaging breast tissues with varying glandular compositions.

Purpose: Better understanding regarding the clinical-economic value of digital breast tomosynthesis (DBT) for breast cancer screening for Medicaid enrollees is needed to help inform sound, value-based decision making. The objective of this study was to conduct a clinical-economic value analysis of DBT for breast cancer screening among women enrolled in Medicaid to assess the potential clinical benefits, associated expenditures, and net budget impact of DBT., Methods: Two annual screening mammography scenarios were evaluated with an economic model: (1) full-field digital mammography and (2) combined full-field digital mammography and DBT. The model focused on two main drivers of DBT value: (1) capacity for DBT to reduce the number of women recalled for additional follow-up imaging and diagnostic services and (2) capacity of DBT to facilitate earlier diagnosis of cancer at earlier stages, when treatment costs are lower., Results: Model analysis results showed that the use of DBT as a mammographic screening modality by Medicaid enrollees potentially reduces the need for follow-up diagnostic services and improves the detection of invasive cancers, allowing earlier, less costly treatment. With the modest incremental reimbursement of $37 for DBT expected for a typical Medicaid claim, annual cost savings from DBT predicted by the model amounts to $8.14 per patient, potentially translating into more than $12,000 savings per year for an average-sized Medicaid plan and as much as $207,000 savings per year for a typical state Medicaid program., Conclusions: Wider adoption of DBT presents an opportunity to deliver value-based care to Medicaid programs and to help address disparities and barriers to accessing preventive care by some of the nation's most vulnerable citizens., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to characterize sternal lesions detected on breast magnetic resonance imaging (MRI), compare MRI detection of sternal lesions with other imaging modalities (bone scan, positron emission tomography/computed tomography (PET/CT) and chest CT), and ascertain how often patient management is altered by discovery of sternal lesions. Retrospective review of 1143 breast MRIs between 2007 and 2012 identified 17 patients with sternal lesions including 15 patients with newly diagnosed breast cancer and two patients with remote history of breast cancer. Tumor size, histopathology, receptor status, nodal and distant metastasis, and images of breast MRI, and other modalities were reviewed. Sternal lesions in 9 of the 17 patients were determined to be malignant (metastasis) either by biopsy or presence of widespread metastases. Sternal lesions in 8 of the 17 were benign, confirmed by biopsy or presumed benign as not detected by other modalities. The malignant group had statistically significant larger breast cancer size (malignant: 6.4 cm; benign: 2.3 cm), a higher percentage of diffuse sternal lesions (malignant: 56%; benign: 0%), and more frequently showed rapid initial enhancing (malignant: 100%; benign: 63%) and delayed washout curves (malignant: 67%; benign: 13%). Although not statistically significant, the malignant group had a higher frequency of invasive lobular carcinoma (malignant: 44%; benign: 13%) and more lymph node involvement (malignant: 78%; benign: 50%). Breast MRI detected more sternal lesions than did bone scan, PET/CT and chest CT. Four of the 17 (24%) patients were upgraded to stage 4 due to unsuspected metastatic sternal lesions on breast MRI. In conclusion, breast MRI is more sensitive than other modalities in detecting sternal lesions. Sternal metastases occur more frequently in aggressive breast cancer and exhibit malignant-type dynamics on breast MRI. Detection of unsuspected sternal metastasis alters staging and improves patient management with more appropriate treatment., (© 2015 Wiley Periodicals, Inc.)

Background: Accurately depicting breast tumors located posteriorly, close to the chest wall musculature, with conventional mammography is a technical challenge., Objective: This study demonstrates the proof of concept of an x-ray fluorescence mapping (XFM) technique to address this issue., Methods: A tissue-equivalent gel phantom is designed to mimic structures in the central part of a compressed breast. The posterior aspect of the breast and adjacent pectoralis major muscle are represented by another 10-mm-thickness breast tissue simulation phantom (BR12) that is attached to the back of the gel phantom as a region of interest (ROI). Two gold nanoparticle (GNP) solutions are embedded into the ROI to simulate varying GNP uptake within breast lesions. The ROI is imaged through performing the XFM technique with an x-ray pencil-beam and a single spectrometer., Results: A 2D mapping of the middle plane in the ROI demonstrates feasibility and matches well the known spatial distribution and different GNP concentrations. 3D reconstruction of the ROI is easily rendered by repeating the 2D mapping process., Conclusion: XFM system geometry and its insensitivity to attenuation coefficients of breast tissue components are unique characteristics that may complement conventional mammography and improve the detection of breast cancers located posteriorly, adjacent to or overlying the chest wall musculature.

Objective: The purpose of this study was to assess the sensitivities and false-detection rates of two computer-aided detection (CADe) systems when applied to digital or film-screen mammograms in detecting the known breast cancer cases from the Digital Mammographic Imaging Screening Trial (DMIST) breast cancer screening population., Materials and Methods: Available film-screen and digital mammograms of 161 breast cancer cases from DMIST were analyzed by two CADe systems, iCAD Second-Look and R2 ImageChecker. Three experienced breast-imaging radiologists reviewed the CADe marks generated for each available cancer case, recording the number and locations of CADe marks and whether each CADe mark location corresponded with the known location of the cancer., Results: For the 161 cancer cases included in this study, the sensitivities of the DMIST reader without CAD were 0.43 (69/161, 95% CI 0.35-0.51) for digital and 0.41 (66/161, 0.33-0.49) for film-screen mammography. The sensitivities of iCAD were 0.74 (119/161, 0.66-0.81) for digital and 0.69 (111/161, 0.61-0.76) for film-screen mammography, both significantly higher than the DMIST study sensitivities (p < 0.0001 for both). The average number of false CADe marks per case of iCAD was 2.57 (SD, 1.92) for digital and 3.06(1.72) for film-screen mammography. The sensitivity of R2 was 0.74 (119/161, 0.66-0.81) for digital, and 0.60 (97/161, 0.52-0.68) for film-screen mammography, both significantly higher than the DMIST study sensitivities (p < 0.0001 for both). The average number of false CADe marks per case of R2 was 2.07 (1.57) for digital and 1.52 (1.45) for film-screen mammography., Conclusion: Our results suggest the use of CADe in interpretation of digital and film-screen mammograms could lead to improvements in cancer detection.

We present a two-step reconstruction method that can qualitatively and quantitatively improve the reconstruction of tissue refractive index (RI) distribution by phase-contrast diffuse optical tomography (PCDOT). In this two-step method, we first recover the distribution of tissue absorption and scattering coefficients by conventional diffuse optical tomography to obtain the geometrical information of lesions, allowing the incorporation of geometrical information as a priori in the PCDOT reconstruction using a locally refined mesh. The method is validated by a series of phantom experiments and evaluated using in vivo data from 42 human subjects. The results demonstrate clear contrast of RI between the lesion and the surroundings, making the image interpretation straightforward. The sensitivity and specificity from these 42 cases are both 81% when RI is used as an imaging parameter for distinguishing between malignant and benign lesions.

Purpose: To determine which factors contributed to the Digital Mammographic Imaging Screening Trial (DMIST) cancer detection results., Materials and Methods: This project was HIPAA compliant and institutional review board approved. Seven radiologist readers reviewed the film hard-copy (screen-film) and digital mammograms in DMIST cancer cases and assessed the factors that contributed to lesion visibility on both types of images. Two multinomial logistic regression models were used to analyze the combined and condensed visibility ratings assigned by the readers to the paired digital and screen-film images., Results: Readers most frequently attributed differences in DMIST cancer visibility to variations in image contrast--not differences in positioning or compression--between digital and screen-film mammography. The odds of a cancer being more visible on a digital mammogram--rather than being equally visible on digital and screen-film mammograms--were significantly greater for women with dense breasts than for women with nondense breasts, even with the data adjusted for patient age, lesion type, and mammography system (odds ratio, 2.28; P < .0001). The odds of a cancer being more visible at digital mammography--rather than being equally visible at digital and screen-film mammography--were significantly greater for lesions imaged with the General Electric digital mammography system than for lesions imaged with the Fischer (P = .0070) and Fuji (P = .0070) devices., Conclusion: The significantly better diagnostic accuracy of digital mammography, as compared with screen-film mammography, in women with dense breasts demonstrated in the DMIST was most likely attributable to differences in image contrast, which were most likely due to the inherent system performance improvements that are available with digital mammography. The authors conclude that the DMIST results were attributable primarily to differences in the display and acquisition characteristics of the mammography devices rather than to reader variability.

Tomosynthesis was developed for mammography, especially breast cancer detection. However, its limited-angular range scan and resultant data incompleteness causes strong image artifacts and distortions. To address this problem, a hybrid imaging method was proposed in our previous work, which combines tomosynthesis and low-resolution CT into a single system to produce fewer artifacts and distortions at a similar dose level. The purpose of this paper is to evaluate the images reconstructed using the proposed method as compared with that using the conventional tomosynthesis method (ML-convex). For that purpose, the projection datasets are acquired in both numerical simulation and phantom experiments on our breast imaging platform. Three kinds of phantoms are used in our work, including a numerical phantom, a physical phantom and 8 in vitro phantoms made of breast specimens. In addition to visual comparison of the reconstructed images, we employ spatial resolution, image contrast, reconstruction error, and convergence rate to evaluate the results quantitatively. It is observed that the results from our method can achieve significantly higher spatial resolution, higher contrast, smaller reconstruction error and faster convergence rate. Besides, a reader study using 8 in vitro phantoms of breast specimens demonstrates the clinical potential of our method, which significantly outperforms the conventional tomosynthesis.

In this study, a series of imaging experiments on biological specimens, including human breast core biopsies, lumpectomy, and chicken tissues, as well as standard phantoms, were performed in an effort to investigate the feasibility of an in-line phase contrast X-ray imaging prototype. The prototype system employed in the study consists of a microfocus X-ray source with tungsten target and a digital flat panel detector, and it can be operated in both conventional attenuation-based imaging mode and in-line phase contrast imaging mode. Biological specimens were imaged in the conventional mode and phase contrast mode with the same source-to-image-detector distance (SID), and phase contrast images exhibited both improved image quality compared with conventional images, and the overshooting patterns along the boundaries in the specimens, which revealed the occurrence of the edge enhancement effect provided by the phase contrast technique. In addition, the performance of the phase contrast mode and conventional mode was compared based on the American College of Radiology (ACR) phantom imaging and contrast detail mammography (CDMAM) phantom-based contrast detail analysis with two experimental settings: one with the same SID and the other with the same object entrance exposure. In both pairs of comparison under our experimental conditions, the phase contrast imaging mode exhibited improved image quality as compared to the conventional mode, which further supported the feasibility of the prototype.

An automated procedure for detecting breast cancer using near-infrared (NIR) tomographic images is presented. This classification procedure automatically extracts attributes from three imaging parameters obtained by an NIR imaging system. These parameters include tissue absorption and reduced scattering coefficients, as well as a tissue refractive index obtained by a phase-contrast-based reconstruction approach. A support vector machine (SVM) classifier is utilized to distinguish the malignant from the benign lesions using the automatically extracted attributes. The classification results of in vivo tomographic images from 35 breast masses using absorption, scattering, and refractive index attributes demonstrate high sensitivity, specificity, and overall accuracy of 81.8%, 91.7%, and 88.6% respectively, while the classification sensitivity, specificity, and overall accuracy are 63.6%, 83.3%, and 77.1%, respectively, when only the absorption and scattering attributes are used. Furthermore, the automated classification procedure provides significantly improved specificity and overall accuracy for breast cancer detection compared to those by an experienced technician through visual examination.

Optimization of exposure parameters (target, filter, and kVp) in digital mammography necessitates maximization of the image signal-to-noise ratio (SNR), while simultaneously minimizing patient dose. The goal of this study is to compare, for each of the major commercially available full field digital mammography (FFDM) systems, the impact of the selection of technique factors on image SNR and radiation dose for a range of breast thickness and tissue types. This phantom study is an update of a previous investigation and includes measurements on recent versions of two of the FFDM systems discussed in that article, as well as on three FFDM systems not available at that time. The five commercial FFDM systems tested, the Senographe 2000D from GE Healthcare, the Mammomat Novation DR from Siemens, the Selenia from Hologic, the Fischer Senoscan, and Fuji's 5000MA used with a Lorad M-IV mammography unit, are located at five different university test sites. Performance was assessed using all available x-ray target and filter combinations and nine different phantom types (three compressed thicknesses and three tissue composition types). Each phantom type was also imaged using the automatic exposure control (AEC) of each system to identify the exposure parameters used under automated image acquisition. The figure of merit (FOM) used to compare technique factors is the ratio of the square of the image SNR to the mean glandular dose. The results show that, for a given target/filter combination, in general FOM is a slowly changing function of kVp, with stronger dependence on the choice of target/filter combination. In all cases the FOM was a decreasing function of kVp at the top of the available range of kVp settings, indicating that higher tube voltages would produce no further performance improvement. For a given phantom type, the exposure parameter set resulting in the highest FOM value was system specific, depending on both the set of available target/filter combinations, and on the receptor type. In most cases, the AECs of the FFDM systems successfully identified exposure parameters resulting in FOM values near the maximum ones, however, there were several examples where AEC performance could be improved.

This article presents a pilot study of multispectral diffuse optical tomography for noninvasively imaging volume fraction and mean size of cellular scattering components in the breast. Cellular morphology images for a total of 14 cases (four malignant breast and ten benign lesions) were obtained. Analyzing the images based on the pathological findings of the cases studied, we found that light scattering in the breast was contributed from both the nucleus and organelles such as mitochondria and nucleolus. Based on the image analysis of these 14 cases, we found that the differences in the mean size and volume fraction between the malignant and benign lesions are significant. The contrast ratio of the average mean size and volume fraction between malignant and benign lesions were calculated to be 3.38 and 2.63. These initial results suggest that cellular mean size and volume fraction may be two new criteria that could be used to differentiate malignant from benign lesions.

Purpose: To retrospectively compare the accuracy of digital versus film mammography in population subgroups of the Digital Mammographic Imaging Screening Trial (DMIST) defined by combinations of age, menopausal status, and breast density, by using either biopsy results or follow-up information as the reference standard., Materials and Methods: DMIST included women who underwent both digital and film screening mammography. Institutional review board approval at all participating sites and informed consent from all participating women in compliance with HIPAA was obtained for DMIST and this retrospective analysis. Areas under the receiver operating characteristic curve (AUCs) for each modality were compared within each subgroup evaluated (age < 50 vs 50-64 vs >or= 65 years, dense vs nondense breasts at mammography, and pre- or perimenopausal vs postmenopausal status for the two younger age cohorts [10 new subgroups in toto]) while controlling for multiple comparisons (P < .002 indicated a significant difference). All DMIST cancers were evaluated with respect to mammographic detection method (digital vs film vs both vs neither), mammographic lesion type (mass, calcifications, or other), digital machine type, mammographic and pathologic size and diagnosis, existence of prior mammographic study at time of interpretation, months since prior mammographic study, and compressed breast thickness., Results: Thirty-three centers enrolled 49 528 women. Breast cancer status was determined for 42,760 women, the group included in this study. Pre- or perimenopausal women younger than 50 years who had dense breasts at film mammography comprised the only subgroup for which digital mammography was significantly better than film (AUCs, 0.79 vs 0.54; P = .0015). Breast Imaging Reporting and Data System-based sensitivity in this subgroup was 0.59 for digital and 0.27 for film mammography. AUCs were not significantly different in any of the other subgroups. For women aged 65 years or older with fatty breasts, the AUC showed a nonsignificant tendency toward film being better than digital mammography (AUCs, 0.88 vs 0.70; P = .0025)., Conclusion: Digital mammography performed significantly better than film for pre- and perimenopausal women younger than 50 years with dense breasts, but film tended nonsignificantly to perform better for women aged 65 years or older with fatty breasts., ((c) RSNA, 2008.)

We present a new method to simultaneously reconstruct the images of oxyhemoglobin, deoxyhemoglobin, and water concentrations, as well as the volume fraction images of the scattering particles using continuous wave multispectral diffuse optical tomography with the absorption and scattering spectral prior constraints. In this method, the nonlinear relationship between the reduced scattering coefficient and the volume fraction and the size of the particles is linearized, allowing direct reconstruction of the volume fraction of scattering particles in tissues. The method is validated by a series of numerical simulations, phantom experiments, and in vivo clinical experiments. The initial clinical results indicate that the volume fraction of scattering particles in a malignant tumor is higher than that in a benign tumor.

Tomosynthesis reconstructs 3-dimensional images of an object from a significantly fewer number of projections as compared with that required by computed tomography (CT). A major problem with tomosynthesis is image artifacts associated with the data incompleteness. In this article, we propose a hybrid tomosynthesis approach to achieve higher image quality as compared with competing methods. In this approach, a low-resolution CT scan is followed by a high-resolution tomosynthesis scan. Then, both scans are combined to reconstruct images. To evaluate the image quality of the proposed method, we design a new breast phantom for numerical simulation and physical experiments. The results show that images obtained by our approach are clearly better than those obtained without such a CT scan.

Mammography is an effective imaging tool for detecting breast cancer at an early stage and is the only screening modality proved to reduce mortality from breast cancer. However, the overlap of tissues depicted on mammograms may create significant obstacles to the detection and diagnosis of abnormalities. Diagnostic testing initiated because of a questionable result at screening mammography frequently causes patients unnecessary anxiety and incurs increased medical costs. Breast tomosynthesis, a new tool that is based on the acquisition of three-dimensional digital image data, could help solve the problem of interpreting mammographic features produced by tissue overlap. Although the technology has not yet been approved by the Food and Drug Administration, breast tomosynthesis has the potential to help reduce recall rates, improve the selection of patients for biopsy, and increase cancer detection rates, especially in patients with dense breasts. Supplemental material available at radiographics.rsnajnls.org/cgi/content/full/27/S231/DC1., (Copyright RSNA, 2007.)

Purpose: To develop and test a computer-aided diagnosis (CAD) system to improve the performance of radiologists in classifying lesions on breast MRI (BMRI)., Materials and Methods: A CAD system was developed that uses a semiautomated segmentation method. After segmentation, 42 features based on lesion shape, texture, and enhancement kinetics were computed, and the 13 best features were selected and used as inputs to a backpropagation neural network (BNN). The BNN was trained and tested using the leave-one-out method on 80 BMRI lesions (37 benign, 43 malignant). Lesion histopathology was used as the reference standard. Five human readers classified the 80 lesions first without and then with CAD assistance. The performance of the computer classifier and the human readers was assessed using receiver operating characteristic curves; the performance of the human readers was also evaluated using multireader multicase (MRMC) analysis., Results: The performance of the human readers significantly improved when aided by the CAD system (P < 0.05). MRMC analysis showed that human reader performance with and without CAD system assistance can be generalized to the population of cases (P < 0.001)., Conclusion: A CAD system based on lesion morphology and enhancement kinetics can improve the performance of human readers in classifying lesions on breast MRI.

Over the past several years there has been an increasing interest in cone-beam computed tomography (CT) for breast imaging. In this article, we propose a new scheme for theoretically exact cone-beam mammo-CT and develop a corresponding Katsevich-type reconstruction algorithm. In our scheme, cone-beam scans are performed along two tilting arcs to collect a sufficient amount of information for exact reconstruction. In our algorithm, cone-beam data are filtered in a shift-invariant fashion and then weighted backprojected into the three-dimensional space for the final reconstruction. Our approach has several desirable features, including tolerance of axial data truncation, efficiency in sequential/parallel implementation, and accuracy for quantitative analysis. We also demonstrate the system performance and clinical utility of the proposed technique in numerical simulations.

The Digital Mammography Imaging Screening Trial (DMIST), conducted under the auspices of the American College of Radiology Imaging Network (ACRIN), is a clinical trial designed to compare the accuracy of digital versus screen-film mammography in a screening population [E. Pisano et al., ACRIN 6652-Digital vs. Screen-Film Mammography, ACRIN (2001)]. Part I of this work described the Quality Control program developed to ensure consistency and optimal operation of the digital equipment. For many of the tests, there were no failures during the 24 months imaging was performed in DMIST. When systems failed, they generally did so suddenly rather than through gradual deterioration of performance. In this part, the utility and effectiveness of those tests are considered. This suggests that after verification of proper operation, routine extensive testing would be of minimal value. A recommended set of tests is presented including additional and improved tests, which we believe meet the intent and spirit of the Mammography Quality Standards Act regulations to ensure that full-field digital mammography systems are functioning correctly, and consistently producing mammograms of excellent image quality.