Denise M. Chough

Digital Breast Tomosynthesis: Observer Performance Study

OBJECTIVE The purpose of this study was to compare in a retrospective observer study the diagnostic performance of full-field digital mammography (FFDM) with that of digital breast tomosynthesis. MATERIALS AND METHODS Eight experienced radiologists interpreted images from 125 selected examinations, 35 with verified findings of cancer and 90 with no finding of cancer. The four display conditions included FFDM alone, 11 low-dose projections, reconstructed digital breast tomosynthesis images, and a combined display mode of FFDM and digital breast tomosynthesis images. Observers rated examinations using the screening BI-RADS rating scale and the free-response receiver operating characteristic paradigm. Observer performance levels were measured as the proportion of examinations prompting recall of patients for further diagnostic evaluation. The results were presented in terms of true-positive fraction and false-positive fraction. Performance levels were compared among the acquisitions and reading modes. Time to view and interpret an examination also was evaluated. RESULTS Use of the combination of digital breast tomosynthesis and FFDM was associated with 30% reduction in recall rate for cancer-free examinations that would have led to recall if FFDM had been used alone (p < 0.0001 for the participating radiologists, p = 0.047 in the context of a generalized population of radiologists). Use of digital breast tomosynthesis alone also tended to reduce recall rates, an average of 10%, although the observed decrease was not statistically significant (p = 0.09 for the participating radiologists). There was no convincing evidence that use of digital breast tomosynthesis alone or in combination with FFDM results in a substantial improvement in sensitivity. CONCLUSION Use of digital breast tomosynthesis for breast imaging may result in a substantial decrease in recall rate.

Detection and Classification of Calcifications on Digital Breast Tomosynthesis and 2D Digital Mammography: A Comparison

OBJECTIVE The purpose of this article is to compare the ability of digital breast tomosynthesis and full field digital mammography (FFDM) to detect and characterize calcifications. MATERIALS AND METHODS One hundred paired examinations were performed utilizing FFDM and digital breast tomosynthesis. Twenty biopsy-proven cancers, 40 biopsy-proven benign calcifications, and 40 randomly selected negative screening studies were retrospectively reviewed by five radiologists in a crossed multireader multimodal observer performance study. Data collected included the presence of calcifications and forced BI-RADS scores. Receiver operator curve analysis using BI-RADS was performed. RESULTS Overall calcification detection sensitivity was higher for FFDM (84% [95% CI, 79-88%]) than for digital breast tomosynthesis (75% [95% CI, 70-80%]). [corrected] In the cancer cohort, 75 (76%) of 99 interpretations identified calcification in both modes. Of those, a BI-RADS score less than or equal to 2 was rendered in three (4%) and nine (12%) cases with FFDM and digital breast tomosynthesis, respectively. In the benign cohort, 123 (62%) of 200 interpretations identified calcifications in both modes. Of those, a BI-RADS score greater than or equal to 3 was assigned in 105 (85%) and 93 (76%) cases with FFDM and digital breast tomosynthesis, respectively. There was no significant difference in the nonparametric computed area under the receiver operating characteristic curves (AUC) using the BI-RADS scores (FFDM, AUC = 0.76 and SD = 0.03; digital breast tomosynthesis, AUC = 0.72 and SD = 0.04 [p = 0.1277]). CONCLUSION In this small data set, FFDM appears to be slightly more sensitive than digital breast tomosynthesis for the detection of calcification. However, diagnostic performance as measured by area under the curve using BI-RADS was not significantly different. With improvements in processing algorithms and display, digital breast tomosynthesis could potentially be improved for this purpose.

Digital Breast Tomosynthesis: A Pilot Observer Study

OBJECTIVE The objective of our study was to assess ergonomic and diagnostic performance-related issues associated with the interpretation of digital breast tomosynthesis-generated examinations. MATERIALS AND METHODS Thirty selected cases were read under three different display conditions by nine experienced radiologists in a fully crossed, mode-balanced observer performance study. The reading modes included full-field digital mammography (FFDM) alone, the 11 low-dose projections acquired for the reconstruction of tomosynthesis images, and the reconstructed digital breast tomosynthesis examination. Observers rated cases under the free-response receiver operating characteristic, as well as a screening paradigm, and provided subjective assessments of the relative diagnostic value of the two digital breast tomosynthesis-based image sets as compared with FFDM. The time to review and diagnose each case was also evaluated. RESULTS Observer performance measures were not statistically significant (p > 0.05) primarily because of the small sample size in this pilot study, suggesting that showing significant improvements in diagnosis, if any, will require a larger study. Several radiologists did perceive the digital breast tomosynthesis image set and the projection series to be better than FFDM (p < 0.05) for diagnosing this specific case set. The time to review, interpret, and rate the examinations was significantly different for the techniques in question (p < 0.05). CONCLUSION Tomosynthesis-based breast imaging may have great potential, but much work is needed before its optimal role in the clinical environment is known.

Comparison of Two-dimensional Synthesized Mammograms versus Original Digital Mammograms Alone and in Combination with Tomosynthesis Images

PURPOSE To assess interpretation performance and radiation dose when two-dimensional synthesized mammography (SM) images versus standard full-field digital mammography (FFDM) images are used alone or in combination with digital breast tomosynthesis images. MATERIALS AND METHODS A fully crossed, mode-balanced multicase (n = 123), multireader (n = 8), retrospective observer performance study was performed by using deidentified images acquired between 2008 and 2011 with institutional review board approved, HIPAA-compliant protocols, during which each patient signed informed consent. The cohort included 36 cases of biopsy-proven cancer, 35 cases of biopsy-proven benign lesions, and 52 normal or benign cases (Breast Imaging Reporting and Data System [BI-RADS] score of 1 or 2) with negative 1-year follow-up results. Accuracy of sequentially reported probability of malignancy ratings and seven-category forced BI-RADS ratings was evaluated by using areas under the receiver operating characteristic curve (AUCs) in the random-reader analysis. RESULTS Probability of malignancy-based mean AUCs for SM and FFDM images alone was 0.894 and 0.889, respectively (difference, -0.005; 95% confidence interval [CI]: -0.062, 0.054; P = .85). Mean AUC for SM with tomosynthesis and FFDM with tomosynthesis was 0.916 and 0.939, respectively (difference, 0.023; 95% CI: -0.011, 0.057; P = .19). In terms of the reader-specific AUCs, five readers performed better with SM alone versus FFDM alone, and all eight readers performed better with combined FFDM and tomosynthesis (absolute differences from 0.003 to 0.052). Similar results were obtained by using a nonparametric analysis of forced BI-RADS ratings. CONCLUSION SM alone or in combination with tomosynthesis is comparable in performance to FFDM alone or in combination with tomosynthesis and may eliminate the need for FFDM as part of a routine clinical study.

Digital Breast Tomosynthesis in the Diagnostic Environment: A Subjective Side-by-Side Review

OBJECTIVE The purpose of our study was to subjectively compare additional mammographic views to digital breast tomosynthesis (DBT) in the characterizing of known masses, architectural distortions, or asymmetries. MATERIALS AND METHODS Four experienced radiologists serially reviewed the imaging studies of 25 women with known masses, including full-field digital mammography (FFDM), additional views, and DBT. After review of the examinations, radiologists rated their relative preference in terms of classifying the finding in question when aided by the additional views versus aided by DBT, their combined diagnostic BI-RADS rating of the finding when both examinations were available, and whether or not they felt comfortable eliminating ultrasound in the specific cases being evaluated as a result of the DBT. RESULTS FFDM and DBT (combined) were perceived to be better for diagnosis in 50% (50/100) of the ratings (25 cases x four readers = 100 ratings) compared with FFDM and additional diagnostic views. Over all readers, 92% of the ratings for verified cancer cases and 50% of the ratings for high-risk cases were rated as BI-RADS 4 or 5. In 12% (12/100) of the ratings, radiologists indicated that the availability of DBT would have eliminated the need for ultrasound as a part of the diagnostic process. CONCLUSION DBT may be an alternative to obtaining additional mammographic views in most but not all cases of patients with a lesion that is not solely calcifications. In a fraction of cases, the use of DBT may eliminate the need for ultrasound.

Localized detection and classification of abnormalities on FFDM and tomosynthesis examinations rated under an FROC paradigm.

OBJECTIVE The purpose of our study was to assess diagnostic performance when retrospectively interpreting full-field digital mammography (FFDM) and breast tomosynthesis examinations under a free-response receiver operating characteristic (FROC) paradigm. MATERIALS AND METHODS We performed FROC analysis of a previously reported study in which eight experienced radiologists interpreted 125 examinations, including 35 with verified cancers. The FROC paradigm involves detecting, locating, and rating each suspected abnormality. Radiologists reviewed and rated both FFDM alone and a combined display mode of FFDM and digital breast tomosynthesis (DBT) (combined). Observer performance levels were assessed and compared with respect to the fraction of correctly identified abnormalities, the number of reported location-specific findings (both true and false), and their associated ratings. The analysis accounts for the number and locations of findings and the location-based ratings using a summary performance index (Λ), which is the FROC analog of the area between the receiver operating characteristic curve and the diagonal (chance) line. RESULTS Under the FROC paradigm, each reader detected more true abnormalities associated with cancer, or a higher true-positive fraction, under the combined mode. In an analysis focused on both the number of findings and associated location-based ratings, each of the radiologists performed better under the combined mode compared with FFDM alone, with increases in Λ ranging from 5% to 34%. On average, under the combined mode radiologists achieved a 16% improvement in Λ compared with the FFDM alone mode (95% CI, 7-26%; p < 0.01). CONCLUSION We showed that DBT-based breast imaging in combination with FFDM could result in better performance under the FROC paradigm.

Matching breast masses depicted on different views a comparison of three methods.

RATIONALE AND OBJECTIVES Computerized determination of optimal search areas on mammograms for matching breast mass regions depicted on two ipsilateral views remains a challenge for developing multiview-based computer-aided detection (CAD) schemes. The purpose of this study was to compare three methods aimed at matching CAD-cued mass regions depicted on two views and the associated impact on CAD performance. MATERIALS AND METHODS The three search methods used (1) an annular (fan-shaped) band, (2) a straight strip perpendicular to the estimated centerline, and (3) a mixed search area bound on the chest wall side by a straight line and an annular arc on the nipple side, respectively. An image database of 200 examinations with positive results depicting the masses on two views and 200 examinations with negative results was used for testing. Two performance assessment experiments were conducted. The first investigated the maximum matching sensitivity as a function of the search area size, and the second assessed the change in CAD performance using these three search methods. RESULTS To include all 200 paired mass regions within the search areas, maximum widths were 28 and 68 mm for the use of the straight strip and the annular band search methods, respectively. When applying a single-image-based CAD scheme to this image database, 172 masses (86% sensitivity) and 523 false-positive (FP) regions (0.33 per image) were detected and cued. Among the positive findings, 92 were cued by the CAD system on both views, and 80 were cued on only one view. In an attempt to match as many of the 172 CAD-cued masses (true-positive [TP] regions) on two views by incrementally reducing the CAD threshold inside the different search areas, the CAD scheme generated 158 TP-TP paired matches with 14 TP-FP paired matches, 142 TP-TP paired matches with 30 TP-FP paired matches, and 146 TP-TP paired matches with 26 TP-FP paired matches, using the methods involving the straight strip, the annular band, and the mixed search areas, respectively. Using the straight strip search method, the CAD also eliminated 25% of FP regions initially cued by the single-image-based CAD scheme and generated the lowest case-based FP detection rate, namely, 15% less than that generated by the annular band method. CONCLUSIONS This study showed that among these three search methods, the straight strip method required a smaller search area and achieved the highest level of CAD performance.

Is an ROC-type Response Truly Always Better Than a Binary Response in Observer Performance Studies?

RATIONALE AND OBJECTIVES The aim of this study was to assess similarities and differences between methods of performance comparisons under binary (yes or no) and receiver-operating characteristic (ROC)-type pseudocontinuous (0-100) rating data ascertained during an observer performance study of interpretation of full-field digital mammography (FFDM) versus FFDM plus digital breast tomosynthesis. MATERIALS AND METHODS Rating data consisted of ROC-type pseudocontinuous and binary ratings generated by eight radiologists evaluating 77 digital mammographic examinations. Overall performance levels were summarized with a conventionally used probability of correct discrimination or, equivalently, the area under the ROC curve (AUC), which under a binary scale is related to Youdens index. Magnitudes of differences in the reader-averaged empirical AUCs between FFDM alone and FFDM plus digital breast tomosynthesis were compared in the context of fixed-reader and random-reader variability of the estimates. RESULTS The absolute differences between modes using the empirical AUCs were larger on average for the binary scale (0.12 vs 0.07) and for the majority of individual readers (six of eight). Standardized differences were consistent with this finding (2.32 vs 1.63 on average). Reader-averaged differences in AUCs standardized by fixed-reader and random-reader variances were also smaller under the binary rating paradigm. The discrepancy between AUC differences depended on the location of the reader-specific binary operating points. CONCLUSIONS The human observers operating point should be a primary consideration in designing an observer performance study. Although in general, the ROC-type rating paradigm provides more detailed information on the characteristics of different modes, it does not reflect the actual operating point adopted by human observers. There are application-driven scenarios in which analysis based on binary responses may provide statistical advantages.

Effect of the Availability of Prior Full-Field Digital Mammography and Digital Breast Tomosynthesis Images on the Interpretation of Mammograms

PURPOSE To assess the effect of and interaction between the availability of prior images and digital breast tomosynthesis (DBT) images in decisions to recall women during mammogram interpretation. MATERIALS AND METHODS Verbal informed consent was obtained for this HIPAA-compliant institutional review board-approved protocol. Eight radiologists independently interpreted twice deidentified mammograms obtained in 153 women (age range, 37-83 years; mean age, 53.7 years ± 9.3 [standard deviation]) in a mode by reader by case-balanced fully crossed study. Each study consisted of current and prior full-field digital mammography (FFDM) images and DBT images that were acquired in our facility between June 2009 and January 2013. For one reading, sequential ratings were provided by using (a) current FFDM images only, (b) current FFDM and DBT images, and (c) current FFDM, DBT, and prior FFDM images. The other reading consisted of (a) current FFDM images only, (b) current and prior FFDM images, and (c) current FFDM, prior FFDM, and DBT images. Fifty verified cancer cases, 60 negative and benign cases (clinically not recalled), and 43 benign cases (clinically recalled) were included. Recall recommendations and interaction between the effect of prior FFDM and DBT images were assessed by using a generalized linear model accounting for case and reader variability. RESULTS Average recall rates in noncancer cases were significantly reduced with the addition of prior FFDM images by 34% (145 of 421) and 32% (106 of 333) without and with DBT images, respectively (P < .001). However, this recall reduction was achieved at the cost of a corresponding 7% (23 of 345) and 4% (14 of 353) reduction in sensitivity (P = .006). In contrast, availability of DBT images resulted in a smaller reduction in recall rates (false-positive interpretations) of 19% (76 of 409) and 26% (71 of 276) without and with prior FFDM images, respectively (P = .001). Availability of DBT images resulted in 4% (15 of 338) and 8% (25 of 322) increases in sensitivity, respectively (P = .007). The effects of the availability of prior FFDM images or DBT images did not significantly change regardless of the sequence in presentation (P = .81 and P = .47 for specificity and sensitivity, respectively). CONCLUSION The availability of prior FFDM or DBT images is a largely independent contributing factor in reducing recall recommendations during mammographic interpretation.

Detection of breast abnormalities using a prototype resonance electrical impedance spectroscopy system: A preliminary study

Electrical impedance spectroscopy has been investigated with but limited success as an adjunct procedure to mammography and as a possible pre-screening tool to stratify risk for having or developing breast cancer in younger women. In this study, the authors explored a new resonance frequency based [resonance electrical impedance spectroscopy (REIS)] approach to identify breasts that may have highly suspicious abnormalities that had been recommended for biopsies. The authors assembled a prototype REIS system generating multifrequency electrical sweeps ranging from 100 to 4100 kHz every 12 s. Using only two probes, one in contact with the nipple and the other with the outer breast skin surface 60 mm away, a paired transmission signal detection system is generated. The authors recruited 150 women between 30 and 50 years old to participate in this study. REIS measurements were performed on both breasts. Of these women 58 had been scheduled for a breast biopsy and 13 had been recalled for additional imaging procedures due to suspicious findings. The remaining 79 women had negative screening examinations. Eight REIS output signals at and around the resonance frequency were computed for each breast and the subtracted signals between the left and right breasts were used in a simple jackknifing method to select an optimal feature set to be inputted into a multi-feature based artificial neural network (ANN) that aims to predict whether a womans breast had been determined as abnormal (warranting a biopsy) or not. The classification performance was evaluated using a leave-one-case-out method and receiver operating characteristics (ROC) analysis. The study shows that REIS examination is easy to perform, short in duration, and acceptable to all participants in terms of comfort level and there is no indication of sensation of an electrical current during the measurements. Six REIS difference features were selected as input signals to the ANN. The area under the ROC curve (Az) was 0.707±0.033 for classifying between biopsy cases and non-biopsy (including recalled and screening negative) and the performance (Az) increased to 0.746±0.033 after excluding recalled but negative cases. At 95% specificity, the sensitivity levels were approximately 20.5% and 30.4% in the two data sets tested. The results suggest that differences in REIS signals between two breasts measured in and around the tissue resonance frequency can be used to identify at least some of the women with suspicious abnormalities warranting biopsy with high specificity.