Special Section Guest Editorial: Introduction to the JMI Special Issue on Advances in Breast Imaging.

The editorial introduces the JMI Special Issue on Advances in Breast Imaging.

Performance comparison of a dedicated total breast PET system with a clinical whole-body PET system: a simulation study.

This paper presents a novel PET geometry for breast cancer imaging. The scanner consists of a 'stadium' (a rectangle with two semi-circles on opposite sides) shaped ring, along with anterior and posterior panels to provide high sensitivity and high spatial resolution for an imaging field-of-view (FOV) that include both breasts, mediastinum and axilla. We simulated this total-breast PET system using GATE and reconstructed the coincidence events using a GPU-based list-mode image reconstruction implementing maximum likelihood expectation-maximization (ML-EM) algorithm. The rear-panel is made up of a single layer of LSO crystals (3.2 × 3.2 × 20 mm3each), while the 'stadium'-shaped elongated ring and the anterior panel are made with dual-layered LSO crystals (1.6 × 1.6 × 6 mm3each). The energy resolution and coincidence resolving time of all detectors are assumed to be 12% and 250 ps full-width-at-half-maximum, respectively. Various sized simulated lesions (4, 5, 6 mm) having 4:1, 5:1, and 6:1 lesion-to-background radioactivity concentration ratios, mimicking different biological uptakes, were strategically located throughout a volumetric torso phantom. We compared system sensitivity and lesion detectability of the dedicated total-breast PET system to a state-of-the-art clinical whole-body PET scanner. The mean sensitivity of the total-breast PET system is 3.21 times greater than that of a whole-body PET scanner in the breast regions. The total-breast PET system also provides better contrast-recovery coefficients for lesions of all sizes and lesion-to-background ratios in the breast when compared to a reference clinical whole-body PET scanner. Receiver operating characteristics (ROC) study shows the area under the ROC curve is 0.948 and 0.924 for the total-breast system and the whole-body PET scanner, respectively, in the detection of 4 mm diameter lesions with 4:1 lesion-to-background ratio. This study demonstrates our novel geometry can provide an imaging FOV larger than conventional PEM systems to simultaneously image both breasts, chest wall and axillae with significantly improved lesion detectability in the breasts when compared to a whole-body PET scanner.

Special Section Guest Editorial: Advances in Breast Imaging.

This guest editorial introduces the special section on Advances in Breast Imaging.

Characterization of CT Hounsfield Units for 3D acquisition trajectories on a dedicated breast CT system.

Hounsfield Units (HU) are used clinically in differentiating tissue types in a reconstructed CT image, and therefore the HU accuracy of a system is important, especially when using multiple sources, novel detector and non-traditional trajectories. Dedicated clinical breast CT (BCT) systems therefore should be similarly evaluated. In this study, uniform cylindrical phantoms filled with various uniform density fluids were used to characterize differences in HU values between simple circular and complex 3D (saddle) orbits. Based on ACR recommendations, the HU accuracy, center-to-edge variability within a slice, and overall variability within the reconstructed volume were characterized for simple and complex acquisitions possible on a single versatile BCT system. Results illustrate the statistically significantly better performance of the saddle orbit, especially close to the chest and nipple regions of what would clinically be a pendant breast volume. The incomplete cone beam acquisition of a simple circular orbit causes shading artifacts near the nipple, due to insufficient sampling, rendering a major portion of the scanned phantom unusable, whereas the saddle orbit performs exceptionally well and provides a tighter distribution of HU values throughout the reconstructed volumes. This study further establishes the advantages of using 3D acquisition trajectories for breast CT as well as other applications by demonstrating the robustness of HU values throughout large reconstructed volumes.

Implementation and CT sampling characterization of a third-generation SPECT-CT system for dedicated breast imaging.

Stand-alone cone beam computed tomography (CT) and single-photon emission computed tomography (SPECT) systems capable of complex acquisition trajectories have previously been developed for breast imaging. Fully three-dimensional (3-D) motions of SPECT systems provide views into the chest wall and throughout the entire volume. The polar tilting capability of the CBCT system has shown improvement in sampling close to the chest wall, while eliminating cone beam artifacts. Here, a single hybrid SPECT-CT system, with each individual modality capable of independently traversing complex trajectories around a common pendant breast volume, was developed. We present the practical implementation of this design and preliminary results of the CT system. The fully 3-D SPECT was nested inside the suspended CT gantry and oriented perpendicular to the CT source-detector pair. Both subsystems were positioned on a rotation stage, with the combined polar and azimuthal motions enabling spherical trajectories. Six trajectories were used for initial evaluation of the tilt capable CT system. The developed system can achieve polar tilt angles with a [Formula: see text] positioning error and no hysteresis. Initial imaging results demonstrate that additional off-axis projection views of various geometric resolution phantoms facilitate more complete sampling, more consistent attenuation value recovery, and markedly improved reconstructions. This system could have various applications in diagnostic or therapeutic breast imaging.

Characterization of X-ray scattering for various phantoms and clinical breast geometries using breast CT on a dedicated hybrid system.

OBJECTIVE: The purpose of this study was to utilize a dedicated breast CT system using a 2D beam stop array to physically evaluate the scatter to primary ratios (SPRs) of different geometric phantoms and prospectively acquired clinical patient data. METHODS: Including clinically unrealizable compositions of 100% glandular and 100% fat, projection images were acquired using three geometrically different phantoms filled with fluids simulating breast tissue. The beam stop array method was used for measuring scatter in projection space, and creating the scatter corrected primary images. 2D SPRs were calculated. Additionally, a new figure of merit, the 3D normalized scatter contribution (NSC) volumes were calculated. RESULTS: The 2D SPR values (0.52-1.10) were primarily dependent on phantom geometry; a secondary dependence was due to their uniform density; 2D SPRs were low frequency and smoothly varying in the uniformly filled phantoms. SPRs of clinical patient data followed similar trends as phantoms, but with noticeable deviations and high frequency components due to the heterogeneous distribution of glandular tissue. The maximum measured patient 2D SPRs were all <0.6, even for the largest diameter breast. These results demonstrate modest scatter components with changing object geometries and densities; the 3D NSC volumes with higher frequency components help visualize scatter distribution throughout the reconstructed image volumes. Furthermore, the SPRs in the heterogeneous clinical breast cases were underestimated by the equivalent density, uniformly filled phantoms. CONCLUSIONS: These results provide guidance on the use of uniformly distributed density and differently shaped phantoms when considering simulations. They also clearly demonstrate that results from patients can vary considerably from 2D SPRs of uniformly simulated phantoms.

Three dimensional dose distribution comparison of simple and complex acquisition trajectories in dedicated breast CT.

PURPOSE: A novel breast CT system capable of arbitrary 3D trajectories has been developed to address cone beam sampling insufficiency as well as to image further into the patient's chest wall. The purpose of this study was to characterize any trajectory-related differences in 3D x-ray dose distribution in a pendant target when imaged with different orbits. METHODS: Two acquisition trajectories were evaluated: circular azimuthal (no-tilt) and sinusoidal (saddle) orbit with ±15° tilts around a pendant breast, using Monte Carlo simulations as well as physical measurements. Simulations were performed with tungsten (W) filtration of a W-anode source; the simulated source flux was normalized to the measured exposure of a W-anode source. A water-filled cylindrical phantom was divided into 1 cm(3) voxels, and the cumulative energy deposited was tracked in each voxel. Energy deposited per voxel was converted to dose, yielding the 3D distributed dose volumes. Additionally, three cylindrical phantoms of different diameters (10, 12.5, and 15 cm) and an anthropomorphic breast phantom, initially filled with water (mimicking pure fibroglandular tissue) and then with a 75% methanol-25% water mixture (mimicking 50-50 fibroglandular-adipose tissues), were used to simulate the pendant breast geometry and scanned on the physical system. Ionization chamber calibrated radiochromic film was used to determine the dose delivered in a 2D plane through the center of the volume for a fully 3D CT scan using the different orbits. RESULTS: Measured experimental results for the same exposure indicated that the mean dose measured throughout the central slice for different diameters ranged from 3.93 to 5.28 mGy, with the lowest average dose measured on the largest cylinder with water mimicking a homogeneously fibroglandular breast. These results align well with the cylinder phantom Monte Carlo studies which also showed a marginal difference in dose delivered by a saddle trajectory in the central slice. Regardless of phantom material or filled fluid density, dose delivered by the saddle scan was negligibly different than the simple circular, no-tilt scans. The average dose measured in the breast phantom was marginally higher for saddle than the circular no tilt scan at 3.82 and 3.87 mGy, respectively. CONCLUSIONS: Not only does nontraditional 3D-trajectory CT scanning yield more complete sampling of the breast volume but also has comparable dose deposition throughout the breast and anterior chest volume, as verified by Monte Carlo simulation and physical measurements.

Characterization of simulated incident scatter and the impact on quantification in dedicated breast single-photon emission computed tomography.

The objective was to characterize the changes seen from incident Monte Carlo-based scatter distributions in dedicated three-dimensional (3-D) breast single-photon emission computed tomography, with emphasis on the impact of scatter correction using the dual-energy window (DEW) method. Changes in scatter distributions with 3-D detector position were investigated for prone breast imaging with an ideal detector. Energy spectra within a high-energy scatter window measured from simulations were linearly fit, and the slope was used to characterize scatter distributions. The impact of detector position on the measured scatter fraction within various photopeak windows and the [Formula: see text] value (ratio of scatter within the photopeak and scatter energy windows) useful for scatter correction was determined. Results indicate that application of a single [Formula: see text] value with the DEW method in the presence of anisotropic object scatter distribution is not appropriate for trajectories including the heart and liver. The scatter spectra's slope demonstrates a strong correlation to measured [Formula: see text] values. Reconstructions of fixed-tilt 3-D acquisition trajectories with a single [Formula: see text] value show quantification errors up to 5% compared to primary-only reconstructions. However, a variable-tilt trajectory provides improved sampling and minimizes quantification errors, and thus allows for a single [Formula: see text] value to be used with the DEW method leading to more accurate quantification.

Snapshot 2D tomography via coded aperture x-ray scatter imaging.

This paper describes a fan beam coded aperture x-ray scatter imaging system that acquires a tomographic image from each snapshot. This technique exploits the cylindrical symmetry of the scattering cross section to avoid the scanning motion typically required by projection tomography. We use a coded aperture with a harmonic dependence to determine range and a shift code to determine cross range. Here we use a forward-scatter configuration to image 2D objects and use serial exposures to acquire tomographic video of motion within a plane. Our reconstruction algorithm also estimates the angular dependence of the scattered radiance, a step toward materials imaging and identification.

Initial In Vivo Quantification of Tc-99m Sestamibi Uptake as a Function of Tissue Type in Healthy Breasts Using Dedicated Breast SPECT-CT.

A pilot study is underway to quantify in vivo the uptake and distribution of Tc-99m Sestamibi in subjects without previous history of breast cancer using a dedicated SPECT-CT breast imaging system. Subjects undergoing diagnostic parathyroid imaging studies were consented and imaged as part of this IRB-approved breast imaging study. For each of the seven subjects, one randomly selected breast was imaged prone-pendant using the dedicated, compact breast SPECT-CT system underneath the shielded patient support. Iteratively reconstructed and attenuation and/or scatter corrected images were coregistered; CT images were segmented into glandular and fatty tissue by three different methods; the average concentration of Sestamibi was determined from the SPECT data using the CT-based segmentation and previously established quantification techniques. Very minor differences between the segmentation methods were observed, and the results indicate an average image-based in vivo Sestamibi concentration of 0.10 ± 0.16 µCi/mL with no preferential uptake by glandular or fatty tissues.

Evaluation of the absorbed dose to the breast using radiochromic film in a dedicated CT mammotomography system employing a quasi-monochromatic x-ray beam.

PURPOSE: A dual modality SPECT-CT prototype system dedicated to uncompressed breast imaging (mammotomography) has been developed. The computed tomography subsystem incorporates an ultrathick K-edge filtration technique producing a quasi-monochromatic x-ray cone beam that optimizes the dose efficiency of the system for lesion imaging in an uncompressed breast. Here, the absorbed dose in various geometric phantoms and in an uncompressed and pendant cadaveric breast using a normal tomographic cone beam imaging protocol is characterized using both thermoluminescent dosimeter (TLD) measurements and ionization chamber-calibrated radiochromic film. METHODS: Initially, two geometric phantoms and an anthropomorphic breast phantom are filled in turn with oil and water to simulate the dose to objects that mimic various breast shapes having effective density bounds of 100% fatty and glandular breast compositions, respectively. Ultimately, an excised human cadaver breast is tomographically scanned using the normal tomographic imaging protocol, and the dose to the breast tissue is evaluated and compared to the earlier phantom-based measurements. RESULTS: Measured trends in dose distribution across all breast geometric and anthropomorphic phantom volumes indicate lower doses in the medial breast and more proximal to the chest wall, with consequently higher doses near the lateral peripheries and nipple regions. Measured doses to the oil-filled phantoms are consistently lower across all volume shapes due to the reduced mass energy-absorption coefficient of oil relative to water. The mean measured dose to the breast cadaver, composed of adipose and glandular tissues, was measured to be 4.2 mGy compared to a mean whole-breast dose of 3.8 and 4.5 mGy for the oil- and water-filled anthropomorphic breast phantoms, respectively. CONCLUSIONS: Assuming rotational symmetry due to the tomographic acquisition exposures, these results characterize the 3D dose distributions in an uncompressed human breast tissue volume for this dedicated breast imaging device and illustrate advantages of using the novel ultrathick K-edge filtered beam to minimize the dose to the breast during fully-3D imaging.

Towards Quantification of Functional Breast Images Using Dedicated SPECT With Non-Traditional Acquisition Trajectories.

Quantification of radiotracer uptake in breast lesions can provide valuable information to physicians in deciding patient care or determining treatment efficacy. Physical processes (e.g., scatter, attenuation), detector/collimator characteristics, sampling and acquisition trajectories, and reconstruction artifacts contribute to an incorrect measurement of absolute tracer activity and distribution. For these experiments, a cylinder with three syringes of varying radioactivity concentration, and a fillable 800 mL breast with two lesion phantoms containing aqueous (99m)Tc pertechnetate were imaged using the SPECT sub-system of the dual-modality SPECT-CT dedicated breast scanner. SPECT images were collected using a compact CZT camera with various 3D acquisitions including vertical axis of rotation, 30° tilted, and complex sinusoidal trajectories. Different energy windows around the photopeak were quantitatively compared, along with appropriate scatter energy windows, to determine the best quantification accuracy after attenuation and dual-window scatter correction. Measured activity concentrations in the reconstructed images for syringes with greater than 10 µCi /mL corresponded to within 10% of the actual dose calibrator measured activity concentration for ±4% and ±8% photopeak energy windows. The same energy windows yielded lesion quantification results within 10% in the breast phantom as well. Results for the more complete complex sinsusoidal trajectory are similar to the simple vertical axis acquisition, and additionally allows both anterior chest wall sampling, no image distortion, and reasonably accurate quantification.

Detailed Characterization of 2D and 3D Scatter-to-Primary Ratios of Various Breast Geometries Using a Dedicated CT Mammotomography System.

With a dedicated breast CT system using a quasi-monochromatic x-ray source and flat-panel digital detector, the 2D and 3D scatter to primary ratios (SPR) of various geometric phantoms having different densities were characterized in detail. Projections were acquired using geometric and anthropomorphic breast phantoms. Each phantom was filled with 700ml of 5 different water-methanol concentrations to simulate effective boundary densities of breast compositions from 100% glandular (1.0g/cm(3)) to 100% fat (0.79g/cm(3)). Projections were acquired with and without a beam stop array. For each projection, 2D scatter was determined by cubic spline interpolating the values behind the shadow of each beam stop through the object. Scatter-corrected projections were obtained by subtracting the scatter, and the 2D SPRs were obtained as a ratio of the scatter to scatter-corrected projections. Additionally the (un)corrected data were individually iteratively reconstructed. The (un)corrected 3D volumes were subsequently subtracted, and the 3D SPRs obtained from the ratio of the scatter volume-to-scatter-corrected (or primary) volume. Results show that the 2D SPR values peak in the center of the volumes, and were overall highest for the simulated 100% glandular composition. Consequently, scatter corrected reconstructions have visibly reduced cupping regardless of the phantom geometry, as well as more accurate linear attenuation coefficients. The corresponding 3D SPRs have increased central density, which reduces radially. Not surprisingly, for both 2D and 3D SPRs there was a dependency on both phantom geometry and object density on the measured SPR values, with geometry dominating for 3D SPRs. Overall, these results indicate the need for scatter correction given different geometries and breast densities that will be encountered with 3D cone beam breast CT.

Characterization of Image Quality for 3D Scatter Corrected Breast CT Images.

The goal of this study was to characterize the image quality of our dedicated, quasi-monochromatic spectrum, cone beam breast imaging system under scatter corrected and non-scatter corrected conditions for a variety of breast compositions. CT projections were acquired of a breast phantom containing two concentric sets of acrylic spheres that varied in size (1-8mm) based on their polar position. The breast phantom was filled with 3 different concentrations of methanol and water, simulating a range of breast densities (0.79-1.0g/cc); acrylic yarn was sometimes included to simulate connective tissue of a breast. For each phantom condition, 2D scatter was measured for all projection angles. Scatter-corrected and uncorrected projections were then reconstructed with an iterative ordered subsets convex algorithm. Reconstructed image quality was characterized using SNR and contrast analysis, and followed by a human observer detection task for the spheres in the different concentric rings. Results show that scatter correction effectively reduces the cupping artifact and improves image contrast and SNR. Results from the observer study indicate that there was no statistical difference in the number or sizes of lesions observed in the scatter versus non-scatter corrected images for all densities. Nonetheless, applying scatter correction for differing breast conditions improves overall image quality.

Is SPECT or CT Based Attenuation Correction More Quantitatively Accurate for Dedicated Breast SPECT Acquired with Non-Traditional Trajectories?

Attenuation correction is necessary for SPECT quantification. There are a variety of methods to create attenuation maps. For dedicated breast SPECT imaging, it is unclear if either SPECT- or CT-based attenuation map would provide the most accurate quantification and whether or not segmenting the different tissue types will have an effect on the qunatification. For these experiments, 99mTc diluted in methanol and water was filled into geometric and anthropomorphic breast phantoms and was imaged with a dedicated dual-modality SPECT-CT scanner. SPECT images were collected using a compact CZT camera with various 3D acquisitions including vertical and 30° tilted parallel beam, and complex sinusoidal trajectories. CT images were acquired using a quasi-monochromatic x-ray source and CsI(T1) flat panel digital detector in a half-cone beam geometry. Measured scatter correction for SPECT and CT were implemented. To compare photon attenuation correction in the reconstructed SPECT images, various volumetric attenuation matrices were derived from 1) uniform SPECT, 2) uniform CT, and 3) segmented CT, populated with different attenuation coefficient values. Comparisons between attenuation masks using phantoms consisting of materials with different attenuation values show that at 140 keV the differences in the attenuation between materials do not affect the quantification as much as the size and alignment of the attenuation map. The CT-based attenuation maps give quantitative values 30% below the actual value, but are consistent. While the SPECT-based attenuation maps can provide within 10% accurate quantitative values, but are less consistent.

Characterizing the MTF in 3D for a Quantized SPECT Camera Having Arbitrary Trajectories.

The emergence of application-specific 3D tomographic small animal and dedicated breast imaging systems has stimulated the development of simple methods to quantify the spatial resolution or Modulation Transfer Function (MTF) of the system in three dimensions. Locally determined MTFs, obtained from line source measurements at specific locations, can characterize spatial variations in the system resolution and can help correct for such variations. In this study, a method is described to measure the MTF in 3D for a compact SPECT system that uses a 16 × 20 cm(2) CZT-based compact gamma camera and 3D positioning gantry capable of moving in different trajectories. Image data are acquired for a novel phantom consisting of three radioactivity-filled capillary tubes, positioned nearly orthogonally to each other. These images provide simultaneous measurements of the local MTF along three dimensions of the reconstructed imaged volume. The usefulness of this approach is shown by characterizing the MTF at different locations in the reconstructed imaged 3D volume using various (1) energy windows; (2) iterative reconstruction parameters including number of iterations, voxel size, and number of projection views; (3) simple and complex 3D orbital trajectories including simple vertical axis of rotation, simple tilt, complex circle-plus-arc, and complex sinusoids projected onto a hemisphere; and (4) object shapes in the camera's field of view. Results indicate that the method using the novel phantom can provide information on spatial resolution effects caused by system design, sampling, energy windows, reconstruction parameters, novel 3D orbital trajectories, and object shapes. Based on these measurements that are useful for dedicated tomographic breast imaging, it was shown that there were small variations in the MTF in 3D for various energy windows and reconstruction parameters. However, complex trajectories that uniformly sample the breast volume of interest were quantitatively shown to have slightly better spatial resolution performance than more simple orbits.

Analysis of a novel offset cone-beam computed mammotomography system geometry for accomodating various breast sizes.

We evaluate a newly developed dedicated cone-beam transmission computed mammotomography (CmT) system configuration using an optimized quasi-monochromatic cone beam technique for attenuation correction of SPECT in a planned dual-modality emission and transmission system for pendant, uncompressed breasts. In this study, we perform initial CmT acquisitions using various sized breast phantoms to evaluate an offset cone-beam geometry. This offset geometry provides conjugate projections through a full 360 degree gantry rotation, and thus yields a greatly increased effective field of view, allowing a much wider range of breast sizes to be imaged without truncation in reconstructed images. Using a tungsten X-ray tube and digital flat-panel X-ray detector in a compact geometry, we obtained initial CmT scans without shift and with the offset geometry, using geometrical frequency/resolution phantoms and two different sizes of breast phantoms. Acquired data were reconstructed using an ordered subsets transmission iterative algorithm. Projection images indicate that the larger, 20 cm wide, breast requires use of a half-cone-beam offset scan to eliminate truncation artifacts. Reconstructed image results illustrate elimination of truncation artifacts, and that the novel quasi-monochromatic beam yields reduced beam hardening. The offset geometry CmT system can indeed potentially be used for structural imaging and accurate attenuation correction for the functional dedicated breast SPECT system.

Evaluation of fully 3-D emission mammotomography with a compact cadmium zinc telluride detector.

A compact, dedicated cadmium zinc telluride (CZT) gamma camera coupled with a fully three-dimensional (3-D) acquisition system may serve as a secondary diagnostic tool for volumetric molecular imaging of breast cancers, particularly in cases when mammographic findings are inconclusive. The developed emission mammotomography system comprises a medium field-of-view, quantized CZT detector and 3-D positioning gantry. The intrinsic energy resolution, sensitivity and spatial resolution of the detector are evaluated with Tc-99m (140 keV) filled flood sources, capillary line sources, and a 3-D frequency-resolution phantom. To mimic realistic human pendant, uncompressed breast imaging, two different phantom shapes of an average sized breast, and three different lesion diameters are imaged to evaluate the system for 3-D mammotomography. Acquisition orbits not possible with conventional emission, or transmission, systems are designed to optimize the viewable breast volume while improving sampling of the breast and anterior chest wall. Complications in camera positioning about the patient necessitate a compromise in these two orbit design criteria. Image quality is evaluated with signal-to-noise ratios and contrasts of the lesions, both with and without additional torso phantom background. Reconstructed results indicate that 3-D mammotomography, incorporating a compact CZT detector, is a promising, dedicated breast imaging technique for visualization of tumors < 1 cm in diameter. Additionally, there are no outstanding trajectories that consistently yield optimized quantitative lesion imaging parameters. Qualitatively, imaging breasts with realistic torso backgrounds (out-of-field activity) substantially alters image characteristics and breast morphology unless orbits which improve sampling are utilized. In practice, the sampling requirement may be less strict than initially anticipated.

A framework for optimising the radiographic technique in digital X-ray imaging.

The transition to digital radiology has provided new opportunities for improved image quality, made possible by the superior detective quantum efficiency and post-processing capabilities of new imaging systems, and advanced imaging applications, made possible by rapid digital image acquisition. However, this transition has taken place largely without optimising the radiographic technique used to acquire the images. This paper proposes a framework for optimising the acquisition of digital X-ray images. The proposed approach is based on the signal and noise characteristics of the digital images and the applied exposure. Signal is defined, based on the clinical task involved in an imaging application, as the difference between the detector signal with and without a target present against a representative background. Noise is determined from the noise properties of uniformly acquired images of the background, taking into consideration the absorption properties of the detector. Incident exposure is estimated or otherwise measured free in air, and converted to dose. The main figure of merit (FOM) for optimisation is defined as the signal-difference-to-noise ratio (SdNR) squared per unit exposure or (more preferably) dose. This paper highlights three specific technique optimisation studies that used this approach to optimise the radiographic technique for digital chest and breast applications. In the first study, which was focused on chest radiography with a CsI flat-panel detector, a range of kV(p) (50-150) and filtration (Z = 13-82) were examined in terms of their associated FOM as well as soft tissue to bone contrast, a factor of importance in digital chest radiography. The results indicated that additive Cu filtration can improve image quality. A second study in digital mammography using a selenium direct flat-panel detector indicated improved SdNR per unit exposure with the use of a tungsten target and a rhodium filter than conventional molybdenum target/molybdenum filter techniques. Finally, a third study focusing on cone-beam computed tomography of the breast using a CsI flat-panel detector indicated that high Z filtration of a tungsten target X-ray beam can notably improve the signal and noise characteristics of the image. The general findings highlight the fact that the techniques that are conventionally assumed to be optimum may need to be revisited for digital radiography.