Comparison of radiation dose between 2D digital stereotactic versus digital breast tomosynthesis-guided breast biopsies.

RATIONALE AND OBJECTIVE: Use of digital breast tomosynthesis (DBT) in breast imaging has necessitated DBT-guided biopsy, however, a single DBT acquisition may result in a greater radiation dose than a single DM acquisition. Our objective was to compare the number of images acquired and the resulting radiation dose of DBT versus DM-guided breast biopsies. METHOD: All biopsies performed on our DM unit from 8/2016 to 1/2017 and on our DM-DBT unit from 8/2017 to 1/2018 were retrospectively reviewed. The number of image acquisitions, average glandular dose (AGD) per acquisition and per procedure were computed and stratified by guidance modality and lesion type. RESULTS: 25 DM-guided biopsies were performed on the DM-only unit, 58 biopsies were performed with DM guidance on the dual unit (DM-DU) and 29 were performed with DBT. The average number of images acquisitions was 10.9 for DM-only unit biopsies, 9.3 images for DM-DU biopsies and 4.3 images for DBT-guided biopsies. Mean procedure AGD for DM-only unit biopsies was 28.77 mGy, versus 22.06 mGy for DM-DU and 10.18 mGy for DBT biopsies. Mean procedure AGD for biopsied calcification-only lesions was 22.3 mGy for DM-DU versus 10.7 mGy for DBT guidance (p < 0.001), with an average of 8.1 images per procedure for DM-DU versus 4.2 for DBT. CONCLUSION: Fewer image acquisitions were obtained with DBT compared with DM guidance, therefore, the overall dose of DBT-guided procedures was less. The dose reduction obtained with DBT is possible across all lesion types, even for calcification-only lesions.

Search for novel contrast materials in dual-energy x-ray breast imaging using theoretical modeling of contrast-to-noise ratio.

Contrast-enhanced (CE) dual-energy (DE) x-ray breast imaging uses a low- and high-energy x-ray spectral pair to eliminate soft-tissue signal variation and thereby increase the detectability of exogenous imaging agents. Currently, CEDE breast imaging is performed with iodinated contrast agents. These compounds are limited by several deficiencies, including rapid clearance and poor tumor targeting ability. The purpose of this work is to identify novel contrast materials whose contrast-to-noise ratio (CNR) is comparable or superior to that of iodine in the mammographic energy range. A monoenergetic DE subtraction framework was developed to calculate the DE signal intensity resulting from the logarithmic subtraction of the low- and high-energy signal intensities. A weighting factor is calculated to remove the dependence of the DE signal on the glandularity of the breast tissue. Using the DE signal intensity and weighting factor, the CNR for materials with atomic numbers (Z) ranging from 1 to 79 are computed for energy pairs between 10 and 50 keV. A group of materials with atomic numbers ranging from 42 to 63 were identified to exhibit the highest levels of CNR in the mammographic energy range. Several of these materials have been formulated as nanoparticles for various applications but none, apart from iodine, have been investigated as CEDE breast imaging agents. Within this group of materials, the necessary dose fraction to the LE image decreases as the atomic number increases. By reducing the dose to the LE image, the DE subtraction technique will not provide an anatomical image of sufficient quality to accompany the contrast information. Therefore, materials with Z from 42 to 52 provide nearly optimal values of CNR with energy pairs and dose fractions that provide good anatomical images. This work is intended to inspire further research into new materials for optimized CEDE breast functional imaging.

Exploring silver as a contrast agent for contrast-enhanced dual-energy X-ray breast imaging.

OBJECTIVE: Through prior monoenergetic modelling, we have identified silver as a potential alternative to iodine in dual-energy (DE) X-ray breast imaging. The purpose of this study was to compare the performance of silver and iodine contrast agents in a commercially available DE imaging system through a quantitative analysis of signal difference-to-noise ratio (SDNR). METHODS: A polyenergetic simulation algorithm was developed to model the signal intensity and noise. The model identified the influence of various technique parameters on SDNR. The model was also used to identify the optimal imaging techniques for silver and iodine, so that the two contrast materials could be objectively compared. RESULTS: The major influences on the SDNR were the low-energy dose fraction and breast thickness. An increase in the value of either of these parameters resulted in a decrease in SDNR. The SDNR for silver was on average 43% higher than that for iodine when imaged at their respective optimal conditions, and 40% higher when both were imaged at the optimal conditions for iodine. CONCLUSION: A silver contrast agent should provide benefit over iodine, even when translated to the clinic without modification of imaging system or protocol. If the system were slightly modified to reflect the lower k-edge of silver, the difference in SDNR between the two materials would be increased. ADVANCES IN KNOWLEDGE: These data are the first to demonstrate the suitability of silver as a contrast material in a clinical contrast-enhanced DE image acquisition system.

The future of medical imaging.

The organisers of this conference have kindly provided me with the forum to look forward and examine the future of medical imaging. My view of the future is informed by my own research directions; thus, I illustrate my vision of the future with results from my own research, and from the research that has motivated me over the last few years. As such, the results presented are specific to the field of breast imaging; however, I believe that the trends presented have general applicability, and hope that this discourse will motivate new research. My vision of the future can be summarised in accordance with three broad trends: (1) increased prevalence of low-dose tomographic X-ray imaging; (2) continuing advances in functional and molecular X-ray imaging; and (3) novel image-based biomarker discovery.

Dual-energy contrast-enhanced digital breast tomosynthesis--a feasibility study.

Contrast-enhanced digital breast tomosynthesis (CE-DBT) is a novel modality for imaging breast lesion morphology and vascularity. The purpose of this study is to assess the feasibility of dual-energy subtraction as a technique for CE-DBT (a temporal subtraction CE-DBT technique has been described previously). As CE-DBT evolves, exploration of alternative image acquisition techniques will contribute to its optimisation. Evaluation of dual-energy CE-DBT was conducted with Institutional Review Board (IRB) approval from our institution and in compliance with federal Health Insurance Portability and Accountability Act (HIPAA) guidelines. A 55-year old patient with a known malignancy in the right breast underwent imaging with MRI and CE-DBT. CE-DBT was performed in the medial lateral oblique view with a DBT system, which was modified under IRB approval to allow high-energy image acquisition with a 0.25 mm Cu filter. Image acquisition occurred via both temporal and dual-energy subtraction CE-DBT. Between the pre- and post-contrast DBT image sets, a single bolus of iodinated contrast agent (1.0 ml kg(-1)) was administered, followed by a 60 ml saline flush. The contrast agent and saline were administrated manually at a rate of approximately 2 ml s(-1). Images were reconstructed using filtered-back projection and transmitted to a clinical PACS workstation. Dual-energy CE-DBT was shown to be clinically feasible. In our index case, the dual-energy technique was able to provide morphology and kinetic information about the known malignancy. This information was qualitatively concordant with that of CE-MRI. Compared with the temporal subtraction CE-DBT technique, dual-energy CE-DBT appears less susceptible to motion artefacts.

Breast dosimetry using high-resolution voxel phantoms.

A computer model of X-ray mammography has been developed, which uses quasi-realistic high-resolution voxel phantoms to simulate the breast. The phantoms have 400 microm voxels and simulate the three-dimensional distributions of adipose and fibro-glandular tissues, Cooper's ligaments, ducts and skin and allow the estimation of dose to individual tissues. Calculations of the incident air kerma to mean glandular dose conversion factor, g, were made using a Mo/Mo spectrum at 28 kV for eight phantoms in the thickness range 40-80 mm and of varying glandularity. The values differed from standard tabulations used for breast dosimetry by up to 43%, because of the different spatial distribution of glandular tissue within the breast. To study this further, additional voxel phantoms were constructed, which gave variations of between 9 and 59% compared with standard values. For accurate breast dosimetry, it is therefore very important to take the distribution of glandular tissues into account.

Calculation of the properties of digital mammograms using a computer simulation.

A Monte Carlo computer model of mammography has been developed to study and optimise the performance of digital mammographic systems. The program uses high-resolution voxel phantoms to model the breast, which simulate the adipose and fibroglandular tissues, Cooper's ligaments, ducts and skin in three dimensions. The model calculates the dose to each tissue, and also the quantities such as energy imparted to image pixels, noise per image pixel and scatter-to-primary (S/P) ratios. It allows studies of the dependence of image properties on breast structure and on position within the image. The program has been calibrated by calculating and measuring the pixel values and noise for a digital mammographic system. The thicknesses of two components of this system were unknown, and were adjusted to obtain a good agreement between measurement and calculation. The utility of the program is demonstrated with the calculations of the variation of the S/P ratio with and without a grid, and of the image contrast across the image of a 50-mm-thick breast phantom.

Update on digital mammography.

On January 28, 2000, the U.S. Food and Drug Administration (FDA) approved the first full-field digital mammography unit for clinical use. The approval occurred approximately ten years after a National Cancer Institute (NCI) expert panel determined that, of all emergent technologies, digital mammography held the greatest potential for improving breast cancer detection [1,2]. Currently, four types of digital mammographic systems are under clinical evaluation. This article will review the information from the early clinical trials on digital mammography and will attempt to define the potential impact of digital mammography on the clinical practice of breast imaging.

Linear response theory for detectors consisting of discrete arrays.

The optical transfer function (OTF) and the noise power or Wiener spectrum are defined for detectors consisting of a lattice of discrete elements with the assumptions of linear response, Gaussian statistics, and stationarity under the discrete group of translations which leave the lattice fixed. For the idealized classification task of determining the presence or absence of a signal under signal known exactly/background known exactly (SKE/BKE) conditions, the Wiener spectrum, the OTF, along with an analog of the gray-scale transfer characteristic, determine the signal-to-noise ratio (SNR), which quantifies the ability of an ideal observer to perform this task. While this result is similar to the established result for continuous detectors, such as screen-film systems, the theory of discrete lattices of detectors must take into account the fact that the lattice only supports a bounded but (in the limit of a detector of arbitrarily great extent) continuous range of frequencies. Incident signals with higher spatial frequencies appear in the data at lower aliased frequencies, and there are pairs of signals which are not distinguishable by the detector (the SNR vanishes for the task of distinguishing such signals). Further, the SNR will in general change if the signal is spatially displaced by a fraction of the lattice spacing, although this change will be small for objects larger than a single pixel. Some of the trade-offs involved in detectors of this sort, particularly in dealing with signal frequencies above those supported by the lattice, are studied in a simple model.

Image processing algorithms for digital mammography: a pictorial essay.

Digital mammography systems allow manipulation of fine differences in image contrast by means of image processing algorithms. Different display algorithms have advantages and disadvantages for the specific tasks required in breast imaging-diagnosis and screening. Manual intensity windowing can produce digital mammograms very similar to standard screen-film mammograms but is limited by its operator dependence. Histogram-based intensity windowing improves the conspicuity of the lesion edge, but there is loss of detail outside the dense parts of the image. Mixture-model intensity windowing enhances the visibility of lesion borders against the fatty background, but the mixed parenchymal densities abutting the lesion may be lost. Contrast-limited adaptive histogram equalization can also provide subtle edge information but might degrade performance in the screening setting by enhancing the visibility of nuisance information. Unsharp masking enhances the sharpness of the borders of mass lesions, but this algorithm may make even an indistinct mass appear more circumscribed. Peripheral equalization displays lesion details well and preserves the peripheral information in the surrounding breast, but there may be flattening of image contrast in the nonperipheral portions of the image. Trex processing allows visualization of both lesion detail and breast edge information but reduces image contrast.

Assessing priorities for allocation of donor liver grafts: survey of public and clinicians.

OBJECTIVES: To compare the priorities of the general public, family doctors, and gastroenterologists in allocating donor livers to potential recipients of liver allograft. DESIGN: Representative quota sampling of 1000 members of the general public and 200 family doctors, and a postal questionnaire of 100 gastroenterologists. SUBJECTS: Respondents were given eight hypothetical case histories (based on real patients) and asked to select recipients for four donor livers. Cases were selected to identify controversial areas such as extremes of age, misuse of alcohol, and intravenous drugs. Respondents were also asked to select the least deserving case and which of seven possible factors (time on waiting list, outcome, age, value to society, return to work, previous use of illicit drugs, and involvement of alcohol in the liver damage) should be used to select patients already listed for transplantation. Focus groups were also held to explore further the reasons for the choices given. RESULTS: There were considerable differences between the three groups in the choice of the recipients, although alcohol use and antisocial behaviour always rated low. For selection of recipients the general public thought that, in decreasing order of importance, age, outcome, and time on the waiting list were the most important factors in selecting recipients; family doctors rated outcome, age, and likely work status after transplantation and the gastroenterologists outcome, work status, and non-involvement of alcohol in the cause of the liver disease as the most important factors. CONCLUSIONS: The views of the public are at variance with those of clinicians. Further debate is required to ensure an equitable and appropriate distribution of a scarce resource.

Analysis of signal propagation in optically coupled detectors for digital mammography: II. Lens and fibre optics.

An x-ray detector for digital x-ray mammography is under investigation, which consists of a phosphor screen coupled by a demagnifying fibre-optic taper to a time-delay integration mode, charge-coupled device (CCD) image array. The signal propagation through such a detector depends on the intensity and angular emission of light from the phosphor screen, the angular acceptance and transmission of light through the optics, and the spectral sensitivity of the CCD to the fluorescent light. The production of light by the phosphor screen was considered in a previous paper. Here, the issues related to the optics are examined. For phosphor screens coupled by lenses with limiting acceptance angles of less than 30 degrees, it was calculated that the coupling efficiency would be 10% greater than would be estimated under the assumption of a Lambertian source. These increases occur because a phosphor screen typically produces light which is more forward directed than a Lambertian source. Similar increases in efficiency are observed when a phosphor screen is coupled to a fibre-optic faceplate or taper. For fibre optics, exact estimation of the optical coupling efficiency requires knowledge of the angular-dependent transmission efficiency of the fibres.

Comparison of receiver operating characteristic curves on the basis of optimal operating points.

RATIONALE AND OBJECTIVES: We developed a method of comparing receiver operating characteristic (ROC) curves on the basis of the utilities associated with their optimal operating points (OOPs). METHODS: OOPs were computed for paired ROC curves on the basis of isocost lines in ROC space with slopes ranging from 0.1 to 3.0. For each pair of OOPs corresponding to a single isocost slope, the difference in costs and the variance of this difference was computed. A sensitivity analysis was thus obtained for the difference between the two curves over a range of isocost slopes. Three published data sets were evaluated using this technique, as well as by comparisons of areas under the curves and of true-positive fractions at fixed false-positive fractions. RESULTS: The OOPs of paired ROC curves often occur at different false-positive fractions. Comparisons of ROC curves on the basis of OOPs may provide results that differ from comparisons of curves at a fixed false-positive fraction. CONCLUSION: ROC curves may be compared on the basis of utilities associated with their OOPs. This comparison of the optimal performance of two diagnostic tests may differ from conventional statistical comparisons.

Analysis of signal propagation in optically coupled detectors for digital mammography: I. Phosphor screens.

The angular emission of light from turbid phosphor screens has been measured and modelled. As a first approximation, turbid phosphor screens have traditionally been modelled as Lambertian sources; however, Giakoumakis et al have previously shown that light emission from turbid phosphor screens is in fact more forward peaked. In this article, we extend the theory of Giakoumakis to include turbid phosphor screens that incorporate a transparent overcoat. The refractive index of the optical coupling medium in contact with the overcoat is shown to have a direct effect on both light output and angular emission from the screen. It was found that simple laws of refraction adequately describe this phenomenon. To model the angular emission of light from such phosphor screens, a term was included to describe the refraction from the overcoat into the adjacent coupling medium. The data obtained are required to calculate the propagation of the signal in a digital mammography detector in which a phosphor screen is optically coupled to a charge-coupled device (CCD) image array.

Analysis of the spatial-frequency-dependent DQE of optically coupled digital mammography detectors.

The effect of optical coupling efficiency on the spatial-frequency-dependent propagation of signal and noise is considered for x-ray image detectors for digital mammography in which a phosphor screen is optically coupled to a charge-coupled device (CCD) image array. For experimental purposes, optical coupling between a Gd2O2S:Tb phosphor screen and a CCD image array was provided by relay lenses. Neutral density filters were inserted between the lenses to vary the optical coupling efficiency without altering the inherent spatial resolution. The total coupling efficiency, defined as the number of electrons (e-) recorded in the CCD per x-ray interaction in the phosphor, was calculated in each case. The modulation transfer function, and the contributions to the total noise power spectrum (NPS) of x-ray quantum noise, secondary quantum noise, and inherent detector noise were measured as a function of coupling efficiency. These data were used to calculate the spatial-frequency-dependent detective quantum efficiency [DQE(f)]. The NPS due to x-ray quantum noise had a significant spatial-frequency dependence for coupling efficiencies of more than 9 e- per x-ray interaction, but little spatial-frequency dependence for coupling efficiencies of less than 2 e- per x-ray interaction. These results indicate that to preserve high spatial-frequency values of DQE(f), and to ensure that images are x-ray quantum-noise limited at high spatial frequencies, a coupling efficiency on the order of 10 e- per x-ray interaction is required.(ABSTRACT TRUNCATED AT 250 WORDS)

Dynamic range requirements in digital mammography.

The dynamic range and the number of gray levels, gamma s, required for digital mammography has been evaluated using an energy transport model. The effects of molybdenum (Mo) and tungsten (W) target spectra and the energy-dependent attenuation by elemental filters, breast tissue, and a phosphor screen were included in the model. For detectors with ideal optical coupling and no inherent detector noise, 3,100 gray levels are discernable (requiring 12 bits per pixel), assuming a 40 kVp, W target spectrum (1.0 mm A1 filtration), a mean glandular dose to a 5 cm thick breast of 0.6 mGy, and an ideal observer with a 5 mm diam viewing aperture. The effects of inherent detector noise and realistic coupling efficiency on gamma s were also examined. For the 40 kVp, W spectrum, a detector with total coupling efficiency of 16 electrons (e-) per x-ray interaction and a dynamic range of 3000 (maximum carrier signal of 1.93 x 10(5) e-/pixel and inherent detector noise of 64 e- pixel) would decrease the number of gray levels that could be resolved by only 2% compared to a detector with ideal coupling and no inherent noise. A detector with a total coupling efficiency of 2.0 electrons per x-ray interaction and a dynamic range of 240 (maximum carrier signal 2.41 x 10(4) e-/pixel and inherent detector noise of 100 e-/pixel) would reduce the number of gray levels by 26% for the 40 kVp spectrum. On the basis of dynamic range, W spectra are preferable for digital mammography, since Mo spectra yielding the same signal-to-noise ratio require a detector with dynamic range twice as large, and with a 30% greater saturation signal. When no scatter rejection method is used, scattered radiation over a 254 cm2 imaging field reduces the number of discernable gray levels by 23% for a 5 cm thick breast and 34% for an 8 cm thick breast.