Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (2024)

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Volume 1 Issue 2 June 2019

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  • Abstract

  • Introduction

  • Conclusion

  • Conflict of interest statement

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Dipti Gupta, MD

Northwestern University Feinberg School of Medicine, Prentice Hospital, Department of Radiology, Chicago, IL

Address correspondence to D.G. (e-mail: dipti.gupta@nm.org)

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Sarah M Friedewald, MD

Northwestern University Feinberg School of Medicine, Prentice Hospital, Department of Radiology, Chicago, IL

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Journal of Breast Imaging, Volume 1, Issue 2, June 2019, Pages 143–150, https://doi.org/10.1093/jbi/wbz009

Published:

18 May 2019

Article history

Received:

21 February 2019

Published:

18 May 2019

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    Dipti Gupta, Sarah M Friedewald, Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong?, Journal of Breast Imaging, Volume 1, Issue 2, June 2019, Pages 143–150, https://doi.org/10.1093/jbi/wbz009

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Abstract

The scroll bar on digital breast tomosynthesis has become an imperative tool that breast imaging radiologists rely on for help in identify lesions on the orthogonal view, targeting breast ultrasound, and performing challenging biopsies for one-view findings. The ability to predict the lesion location using the scroll bar not only saves time in the diagnostic setting but also reduces screening recalls when a finding can be confirmed as dermal. It is important, however, to recognize settings in which the location prediction can be misleading, such as for lesions in thin breast tissue or the anterior portion of the breast or if the breast is not appropriately positioned. In these situations, radiologists can use other diagnostic tools for problem solving.

digital breast tomosynthesis, lesion localization, scroll bar

ACCME Accreditation Statement:

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the American College of Radiology and Society of Breast Imaging. The American College of Radiology is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement:

The American College of Radiology designates this activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Credits awarded for this enduring activity are designated “SA-CME” by the American Board of Radiology (ABR) and qualify toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong Learning and Self-assessment.

Technologists:

The American College of Radiology is approved by the American Registry of Radiologic Technologists (ARRT) as a Recognized Continuing Education Evaluation Mechanism (RCEEM) to sponsor and/or review Continuing Medical Educational programs for Radiologic Technologists and Radiation Therapists.

The American College of Radiology designates this educational activity as meeting the criteria for 1 Category A credit hours of the ARRT.

Key Messages

  • The scroll bar on digital breast tomosynthesis (DBT) can help identify lesions on the orthogonal view, direct targeted breast ultrasound, and guide the approach for biopsy of one-view findings.

  • There are specific scenarios when the predicted lesion location on the scroll bar can be misleading, such as for lesions in thin breast tissue and the anterior portion of the breast, or if the breast is not appropriately positioned.

  • In some cases, the location of the lesion relative to the nipple on the scroll bar can help predict its true position.

Introduction

The effectiveness of digital breast tomosynthesis (DBT) in the screening setting has been validated in several studies that show both increased cancer detection rates and decreased recall rates with DBT compared with digital mammography alone (1, 2). Tomosynthesis has also become an important tool in the diagnostic setting to evaluate and guide biopsy of asymmetries and one-view architectural distortions (3–5).

The Breast Imaging Reporting and Data System (BI-RADS) lexicon published by the American College of Radiology describes an asymmetry as a finding only seen on one of the two standard views of the breast (6). According to the lexicon, an apparent mass only seen on one view should still be characterized as an asymmetry. In a retrospective review of one-view findings on screening mammograms, Sickles found that 82.7% of the recalls were due to a summation artifact, and cancers were only found in 1.8% (7). Interestingly, however, in reviews of missed cancers, 9%–38% of missed cancers were retrospectively visible as a one-view finding (8–10). Characterization and localization of one-view findings has improved significantly with the use of DBT, along with the ability to sample these findings using tomosynthesis-guided biopsy.

Lesion localization on digital mammography

Before DBT, the tool kit for mammographic evaluation of one-view findings was limited. The lateral view is the first step in localizing lesions only seen on the mediolateral oblique (MLO) views (Figure 1). For example, if an area of architectural distortion (AD) only seen on the MLO view rises to a higher position on the lateral view, the finding will be located in the medial breast.

Figure 1.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (4)

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Lesion triangulation. If a finding is identified on the craniocaudal (CC) and mediolateral oblique (MLO) views, the location on the lateral view can be predicted by drawing a straight line connecting the lesion between the standard CC (A), MLO (B), and mediolateral (ML) (C) views.

Craniocaudal (CC) rolled views can be performed for lesions only seen on the CC view, where the superior breast tissue is rolled slightly (Figure 2). Rolling of the tissues changes the relationship of the superior and inferior breast tissue with respect to each other. When obtaining a CC rolled view, the superior portion of the breast can be rolled medially (CCRM) or laterally (CCRL). If the abnormality moves in the direction of the roll, that is, the lesion moves more laterally on the CCRL and more medially on the CCRM, it will be in the superior breast.

Figure 2.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (5)

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Rolled views for localization. A developing asymmetry (arrow) on the CC view (A) moves more laterally (arrow) on the CC–rolled medial (CCRM) view (B), which localizes it to the inferior breast. A targeted breast ultrasound (C) of the left lower inner quadrant shows an irregular, hypoechoic mass at 7:00 (arrow).

Finally, step oblique views involve changing the obliquity of the X-ray beam in 10–15 degree increments starting from the view that the abnormality is seen. The goal of step oblique views is to obtain a view only slightly different from the one where the asymmetry was seen. As the obliquity of the X-ray beam changes, a real finding will persist, whereas an asymmetry caused by summation will resolve (11). The lateral view, rolled views, and step oblique views all serve to discern a persistent finding from a summation shadow by varying the angle of the beam or the position of the breast tissue.

DBT technology

DBT is a mammographic technique whereby multiple low-dose projection images are acquired in an arc across the breast and are reconstructed into thin “slices.” (12–15) One millimeter single section reconstruction images can be reviewed on a workstation, allowing a 3D estimation of the location of the lesion relative to the breast tissue, thereby reducing the effects of tissue superimposition (16).

The total number of reconstruction slices depends on the thickness of the breast. For example, if the compressed breast thickness is 5 cm, and slices are at 1mm intervals, there will be approximately 50 total slices. It is important to note that 5 additional reconstructed slices are added on to the nondetector (ie, the compression paddle) side of the image, as the edge of the breast can be difficult to define because of its curvature, and it is difficult to measure compression accurately down to the millimeter (17). Therefore, for our example, there will 55 total slices, including the extra 5 slices on the CC view added to the superior portion.

Each slice is assigned a slice number and is accompanied by a scroll bar that marks the position of that slice relative to the entire stack. In our example, a lesion on slice 25 of the CC view is likely in the central portion of the breast on the lateral view. This information from the scroll bar helps localize the position of the lesion on the orthogonal view.

Problem solving using the scroll bar

The ability to localize one-view findings using the scroll bar can help target breast ultrasound, guide the approach for stereotactic or tomosynthesis-guided biopsy, and confirm the dermal location of superficial findings.

When an indeterminate finding is only seen on one view, the scroll bar can help localize where to search for the lesion on the orthogonal view. With this guidance and a focused search, a subtle correlate is often identified on the orthogonal view, where the finding may originally have been felt to be occult (Figure 3). Even when a correlate is not identified on the orthogonal view, the location on the scroll bar can help target breast ultrasound, which can be especially useful in patients with large or complicated breasts. Instead of scanning half of the breast, a quadrant of the breast can be honed in on, which can save time and prevent incidental findings.

Figure 3.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (6)

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An area of architectural distortion (circle) is best seen on the right CC view (A), central to the nipple, localizing to the upper breast on the scroll bar. The distortion (circle) is not readily apparent on the MLO view (B) until the upper breast is more thoroughly investigated. Targeted ultrasound (C) of the upper central right breast demonstrates an irregular mass (arrow) at 12:00, which yielded invasive carcinoma with mixed ductal and lobular features on biopsy.

If a suspicious finding is identified on one view and no correlate is identified on ultrasound, targeting the lesion for a stereotactic core biopsy can often be challenging. This is especially the case for architectural distortion, which is often more conspicuous on the CC view than on the MLO or lateral views. The scroll bar can be used to guide the approach for the biopsy in this situation. For example, for an area of architectural distortion only seen on the CC view that localizes to the superior breast on the scroll bar, a superior approach should be selected. Using tomosynthesis for biopsy guidance can improve the confidence for targeting one-view architectural distortion (Figure 4).

Figure 4.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (7)

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Using the scroll bar to determine the biopsy approach. Architectural distortion (circle) in the outer anterior left breast is only identified on the CC view (A). A superior approach was selected for the tomosynthesis-guided biopsy because the scroll bar localized the distortion to the upper breast. Postprocedure mammogram (B, C) demonstrates the biopsy clip (arrow) in an appropriate position in the upper outer breast. Pathology yielded invasive ductal carcinoma, grade 2.

The scroll bar can also be used to confirm dermal calcifications and reduce recall rates. While skin calcifications often have classic lucent centers, sometimes calcifications may not be identifiable as dermal, based on morphology. Assuming the skin thickness is 3 mm, the skin is imaged on the first and last 3 slices on DBT, where it is either touching the compression paddle or the detector. Calcifications and masses on those slices can therefore be confirmed as dermal (Figure 5). However, calcifications can still be dermal and not be within the first or last 3 slices, localized in the areas where the skin in not touching the equipment. For example, because of the curvature of the breast, the skin near the nipple is located deeper in the stack compared with the posterior portion of the breast, where the breast is thicker. Last, as the extra 5 slices are added to the compression paddle side of the breast, if the measured compression thickness is perfectly accurate, dermal calcifications may appear deeper in the stack on the nondetector side (18). If calcifications are suspected to be dermal but not within the first or last 3 slices, either a reverse view can be obtained with the calcifications against the detector or a skin tangential study can be performed.

Figure 5.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (8)

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Using the scroll bar to confirm dermal location. An asymmetry in the right inferior breast (circle) is seen on the first slice of the MLO tomosynthesis view (A). The technologist realized the mole marker had fallen off at the time of the screening exam. The MLO view (B) was repeated with a round mole marker in place, and it confirms the asymmetry to be dermal.

Pitfalls with DBT scroll bar localization

While the scroll bar usually accurately localizes lesions on the orthogonal view, there are a few specific situations where the scroll bar can lead the reader astray. Recognizing the factors that lead to the seemingly inaccurate lesion localization can help prevent interpretation errors.

Location Based on the True Lateral View

It is important to remember that the scroll bar predicts the lesion location on the orthogonal view. At the time of screening mammography, nonorthogonal CC and MLO views are performed, and the principles of triangulation have to be taken in to account. When viewing the scroll bar on the CC view, the location of the lesion is predicted on the true lateral view, not the MLO view (Figure 6). As discussed earlier, medial lesions rise higher on a true lateral view compared with the MLO view. Therefore, when a lesion is medial on the CC view, the scroll bar will predict the lesion location to be higher than what is seen on the MLO view. Conversely, a lateral lesion will be located lower on the scroll bar than expected based on the MLO view because the scroll bar reflects that the lesion will be lower in location on a true lateral view compared with the MLO view.

Figure 6.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (9)

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Triangulation using tomosynthesis. An irregular mass (circle) is seen central to the nipple on the MLO view (A) in the left breast, but it localizes to the inferior portion on the CC view scroll bar (B). As lesions in the outer breast fall on the lateral view, the ML view (C) confirms the mass to be in the lower breast (circle). On ultrasound (D), an irregular mass (arrow) is seen at the left 5:00 position, corresponding to the finding on mammography.

Nipple Positioning

When the breast is appropriately positioned, the nipple should be in the center of the breast and the center of the scroll bar, demarcating the superior and inferior breast on the lateral view and medial and lateral portions on the CC view. However, in some patients, the nipple may not be in the center of the breast or more commonly, it may be malpositioned in one extreme direction.

In these cases, the reader should note the scroll bar location when the nipple is in focus and use that as a reference for localizing the lesion (Figure 7). For example, in a patient with reduction mammoplasty where the nipple is elevated (in focus toward the head on the scroll bar), a lesion toward the middle of the scroll bar on the CC view would actually be in the inferior breast.

Figure 7.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (10)

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The scroll bar is misleading when the nipple is malpositioned. The tomosynthesis right MLO slice (A) shows that the nipple is not optimally positioned and the breast is drooping. The mass (circle) is localized on the MLO scroll bar to the lateral breast, although the true position is in the medial breast (circle) on the CC view (B). The nipple (arrow) is in focus toward the lateral breast and not in the middle of the scroll bar (C). The relative location of the mass on the scroll bar is closer to medial compared with the position of the nipple.

Lesions Localizing to the Detector Side

Lesions may erroneously project closer to the detector on the scroll bar in patients with thin breast tissue and when the finding is located in the anterior portion of the breast.

To account for inaccuracies in measurement of the compression thickness, 5 additional slices are added to the stack toward the compression paddle side of the breast to ensure that a portion of the breast is not excluded on the reconstructed images. While the extra 5 slices do not make a significant difference in the majority of cases, in patients with very thin breasts, the extra slices can cause a lesion to localize closer to the detector side (Figure 8). For example, in a patient with a compression thickness of 20 mm, the 5 extra slices account for a significant portion of the image stack, and there are 20% more images toward the compression paddle side of the breast. In these cases, a lesion in the center of the breast will appear to be closer to the detector side on the scroll bar.

Figure 8.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (11)

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Localization inaccuracy in thin breasts. A group of coarse heterogeneous calcifications (circle) in the central breast on the MLO view (A) localizes to the inferior breast on the CC view scroll bar (B). Additional image information reveals that the compressed breast thickness is 18 mm (arrow). The extra 5 slices on the compression paddle side in this thin breast localize the lesion closer to the detector side.

Because of the curvature of the breast, the anterior portion of the breast is usually thinner and more compressible than the posterior portion is. The scroll bar, however, reflects the thickness of the entire breast, and thus the anterior portion may be included in only a small portion of the scroll bar. Anterior lesions may project toward the detector side of the scroll bar, as the compression paddle flexes toward the detector in the anterior portion, where the breast is thinner. In such cases, it is helpful to assess the location of the lesion in relation to the nipple, instead of solely relying on the location determined by the scroll bar (Figure 9). The principle of localization on the scroll bar assumes even compression throughout the breast. There may also be differences in compressibility of the breast based on tissue composition that may lead to uneven compression and errors in localization. In such cases, the position of the lesion on the scroll bar relative to the nipple may again be used to aid in localization.

Figure 9.

Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (12)

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Localization of anterior breast lesions. Routine right CC and MLO views (A, B) demonstrate a focal asymmetry (circle) in the right upper outer quadrant anterior depth. The scroll bar on the tomosynthesis CC view (C) localizes the mass (circle) toward the feet (detector side of the scroll bar.) The nipple (arrow) is also best in focus toward the feet (D), instead of the middle of the scroll bar, and it localizes lower on the scroll bar relative to the asymmetry. Therefore, the asymmetry is correctly localized relative to the nipple.

Superficial lesions

In the vast majority of the cases, the first 3 slices in the scroll bar are imaging of skin. Findings in these slices can be considered dermal and, therefore, do not need additional diagnostic evaluation. Rarely, in patients with very thin breast tissue and thin skin, it is possible that findings in these first few slices are already within the breast parenchyma. If there is doubt at the time of the exam, a skin tangential study can be performed to confirm whether a finding is dermal (Figure 10).

Figure 10.

Localization of a superficial lesion. A group of calcifications (circles) in the right lower outer quadrant is in focus on slice 3 of the CC and MLO views (A, B). The tangential view (C) shows that the calcifications (circle) are superficial but not dermal. The specimen radiograph (D) from the stereotactic core needle biopsy confirms the targeted calcifications (circle) and yielded ductal carcinoma in situ. It is likely in the unusual case that the skin thickness was less than 3 mm, and, therefore, the calcification location may mislead the radiologist, suggesting that the calcifications were dermal.

Additionally, superficial lesions are more susceptible to rolling with the skin if the breast is not positioned appropriately. This is especially true in large breasts, where the CC view is more susceptible to the rolling of breast tissues. If there is inappropriate positioning, it may seem that the location predicted by the scroll bar on the orthogonal view was inaccurate. In such cases, a repeat view can be performed to confirm that the predicted location on the scroll bar is correct and that the apparent error was positional.

Conclusion

It is important for the breast imaging radiologist to realize that while the scroll bar on DBT is useful for lesion localization, there are specific scenarios when it may not appear accurate. Alternative cues such as the position of the lesion relative to the nipple on the scroll bar can be used to aid localization in such cases. Knowledge of the pitfalls with the scroll bar on DBT can prevent interpretation errors and allow for accurate localization of findings only seen on one view.

Conflict of interest statement

D.G. declares no conflicts. S.M.F. is a recipient of a research grant and is a scientific advisory board member of Hologic, Inc.

To obtain CME for this article, go to: https://sbi-online.peachnewmedia.com

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© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Topic:

  • biopsy
  • nipples
  • problem solving
  • ultrasonography, breast
  • breast
  • diagnosis
  • breast imaging
  • breast tissue
  • digital breast tomosynthesis
  • radiologists
  • chief complaint

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Lesion Localization Using Digital Breast Tomosynthesis: Where Did I Go Wrong? (2024)

FAQs

How accurate is digital breast tomosynthesis? ›

The average sensitivity of BT was higher than that of DM (∼90% vs ∼79%; 95% confidence interval of difference: 0.036, 0.108) while the average false-positive fraction was not significantly different (95% confidence interval of difference: −0.117, 0.010).

Where is a lesion located on mammogram? ›

In the MLO view, lesions above the nipple are in the superior/upper quadrant while lesions below the nipple are in the inferior/lower quadrant. The superior quadrant spans from 9:00 and 3:00, while lower quadrant spans from 3:00 to 9:00 in a clockwise orientation (Figure 2).

What are the limitations of tomosynthesis? ›

Disadvantages of tomosynthesis include increased radiation exposure and reading time. The radiation exposure is approximately double the usual radiation dose associated with mammography and can be even greater in patients with dense or thick breasts.

How many false positive results of mammography screening in the era of digital breast tomosynthesis? ›

Comparing modalities, the overall cumulative probability of at least 1 false-positive recall after 10 years of screening with tomosynthesis vs digital mammography was 49.6% (95% CI, 49.0%-50.2%) vs 56.3% (95% CI, 56.0%-56.7%) for annual screening (difference, –6.7; 95% CI, –7.4 to –6.1) and 35.7% (95% CI, 34.8%-36.6%) ...

What is the false positive rate for tomosynthesis? ›

Mammography versus tomosynthesis for breast cancer screening

The researchers estimated that over 10 years of annual tomosynthesis screening, 50% of women will experience at least one false positive recall, 17% a false positive short-interval follow-up recommendation, and 11% a false positive biopsy recommendation.

Should I be worried about a breast lesion? ›

Most often they're noncancerous (benign), particularly in younger women. Still, it's important to have any breast lump evaluated by a health care provider, especially if it's new or if one breast feels different from the other breast.

What is a suspicious lesion? ›

A lesion that is rough, oozing, bleeding, or scaly. A sore lesion that will not heal. Pain, itching, or tenderness to a lesion.

Do breast lesions need to be removed? ›

If the lump is greater than 3cm in diameter, painful, growing or shows concerning features, surgical removal is often recommended. Fibroadenomas do not cause cancer, and cancer is no more likely to develop within the lump than anywhere else in the breast.

What is the recall rate for tomosynthesis? ›

Recall rates and cancer detection rates varied with the method of screening mammography. The mean recall rate was highest for 2D analog examinations (11.2%), followed by 2D digital examinations (10.8%) and then 3D tomosynthesis examinations (9.4%).

Is tomosynthesis a biopsy? ›

What is a stereotactic/tomosynthesis guided breast biopsy? A core needle biopsy is a procedure to remove tissue from the breast for examination by a pathologist. Stereotactic or tomosynthesis guided means that we use x-rays to guide the needle.

Is a mammogram better with or without tomosynthesis? ›

Tomosynthesis produces a more detailed image of your breast than a standard mammogram. It's better at detecting cancer and reducing false-positive results in dense breast tissue.

Is tomosynthesis better for dense breasts? ›

To overcome the limitations of mammography, digital breast tomosynthesis (DBT) has been developed to improve cancer detection and reduce the rate of false positives by removing overlapping tissues [7,8,9], especially in women with dense breasts [10] and those under the age of 50 years [11].

What are the disadvantages of 3D mammograms? ›

Cons: Potential higher cost: 3D mammograms tend to be more expensive than 2D mammograms, and may not be covered by insurance. Availability: While 3D mammography is becoming more widespread, it may not yet be available at every healthcare facility, limiting access for some patients.

What are the disadvantages of contrast enhanced mammography? ›

4. Due to weak enhancement on CEM, the poster authors noted that it may be difficult to differentiate some malignancies, such as invasive lobular carcinoma, papillary carcinoma, and mucinous carcinoma, from background parenchymal enhancement (BPE).

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