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  • 1. Breast tomosynthesis reducesBreast tomosynthesis reduces radiologist performanceradiologist performance variability compared to digitalvariability compared to digital mammographymammography Andrew SmithAndrew Smith11, Elizabeth Rafferty, Elizabeth Rafferty22, Loren Niklason, Loren Niklason11 11 Hologic, Inc., Bedford MA, USAHologic, Inc., Bedford MA, USA 22 Massachusetts General Hospital, Boston MA, USAMassachusetts General Hospital, Boston MA, USA andrew.smith@hologic.comandrew.smith@hologic.com
  • 2. Study GoalsStudy Goals Measure radiologist variability ofMeasure radiologist variability of performance of 2D+3D comparedperformance of 2D+3D compared to 2D:to 2D: –– Area under ROC curveArea under ROC curve –– Decision to recallDecision to recall
  • 3. Tomosynthesis AcquisitionTomosynthesis Acquisition XX--ray tube moves in an arc across the breastray tube moves in an arc across the breast 11 projections over 1511 projections over 15°° TotalTotal tomotomo dose matched to 2D dose (FFDM)dose matched to 2D dose (FFDM) Reconstruction into 1 mm transverse slicesReconstruction into 1 mm transverse slices Digital detector Compression plate Breast X-ray tube Reconstructed 1 mm planes
  • 4. Data CollectionData Collection StudyStudy tomotomo in screening environment. 1000in screening environment. 1000 patients. Diagnostic needed to enrich with cancers.patients. Diagnostic needed to enrich with cancers. Imaged using 2D (FFDM: Selenia),Imaged using 2D (FFDM: Selenia), Imaged using 3D (Tomosynthesis prototype)Imaged using 3D (Tomosynthesis prototype) Both views (CC, MLO), both breasts.Both views (CC, MLO), both breasts. Previous studies suggest both CC and MLOPrevious studies suggest both CC and MLO tomotomo needed for optimal performanceneeded for optimal performance Institution Review Board/Informed patient consentInstitution Review Board/Informed patient consent
  • 5. Why 3D+2D, and not 3D alone?Why 3D+2D, and not 3D alone? Tomosynthesis (3D) will reduce tissueTomosynthesis (3D) will reduce tissue overlap compared to FFDM (2D), mostlyoverlap compared to FFDM (2D), mostly needed for massesneeded for masses Having 2D exam speeds up search forHaving 2D exam speeds up search for microcalcificationsmicrocalcifications There will be a transition period when 2D isThere will be a transition period when 2D is useful: comparison to priors, use of 2D as golduseful: comparison to priors, use of 2D as gold standard.standard. System supports single breast compressionSystem supports single breast compression acquisition of both 2D and 3Dacquisition of both 2D and 3D
  • 6. Acquisition showing 3DAcquisition showing 3D followed by 2D examfollowed by 2D exam
  • 7. Reader Study ProtocolReader Study Protocol ~310 patients, includes~310 patients, includes normalsnormals, recalls,, recalls, benign lesions and 51 cancersbenign lesions and 51 cancers 27 readers, radiologists with range of27 readers, radiologists with range of mammography experiencemammography experience Readers had no prior experience withReaders had no prior experience with tomosynthesistomosynthesis Readers were trained over 2 day sessionReaders were trained over 2 day session
  • 8. Assessment MethodologyAssessment Methodology Read images on dedicated mammography workstationRead images on dedicated mammography workstation Read and score the 2D:Read and score the 2D: •• Initial BIRADS 0, 1, or 2Initial BIRADS 0, 1, or 2 •• Forced BIRADS (1Forced BIRADS (1--5)5) •• Probability of Malignancy (POM) from 0 to 100%Probability of Malignancy (POM) from 0 to 100% Read 3D and score (2D+3D) using same methodsRead 3D and score (2D+3D) using same methods •• Initial BIRADS 0, 1, or 2Initial BIRADS 0, 1, or 2 •• Forced BIRADS (1Forced BIRADS (1--5)5) •• Probability of Malignancy (POM) from 0 to 100%Probability of Malignancy (POM) from 0 to 100%
  • 9. Data AnalysisData Analysis Compare 2D and (2D+3D)Compare 2D and (2D+3D) Compute ROC curve from Probability ofCompute ROC curve from Probability of MalignancyMalignancy ROC analysis: MultiROC analysis: Multi--reader multireader multi--casecase DBM MRMC Beta 2 softwareDBM MRMC Beta 2 software
  • 10. Examples of readersExamples of readers’’ ROC curvesROC curves
  • 11. ROC Analysis:ROC Analysis: Area under ROC Curve (AUROC)Area under ROC Curve (AUROC) AUROC of 3D+2D superior to 2D forAUROC of 3D+2D superior to 2D for every readerevery reader Look atLook at radiologist variationradiologist variation, i.e., i.e. standard deviation of AUROCstandard deviation of AUROC Equality of Variance test forEquality of Variance test for statistical significancestatistical significance
  • 12. Radiologist Variability with 2D and 2D+3D 2D+3D 2D
  • 13. All CasesAll Cases 0.0230.032Standard Deviation AUROC 0.8950.825Mean AUROC 2D+3D2D AUROC 2D+3D variability 72% of 2D,AUROC 2D+3D variability 72% of 2D, variances equal p=0.11variances equal p=0.11
  • 14. ““AveragedAveraged”” ROC CurvesROC Curves All casesAll cases CalcsCalcs onlyonly NoNo calcscalcs
  • 15. Cases involving CalcificationsCases involving Calcifications 0.0480.051Standard Deviation AUROC 0.8560.840Mean AUROC 2D+3D2D AUROC 2D+3D variability 93% of 2D,AUROC 2D+3D variability 93% of 2D, variances equal p=0.73variances equal p=0.73
  • 16. Cases withoutCases without CalcsCalcs 0.0270.044Standard Deviation AUROC 0.9220.827Mean AUROC 2D+3D2D AUROC 2D+3D variability 63% of 2D,AUROC 2D+3D variability 63% of 2D, variances equal p = 0.02variances equal p = 0.02
  • 17. Decision to Recall,Decision to Recall, nonnon--cancer cases (BIRADS 0)cancer cases (BIRADS 0) 0.5300.413Kappa 78.7%70.9%Agreed on recall decision 2D+3D2D Kappa differences statistically significantKappa differences statistically significant
  • 18. Image ExamplesImage Examples
  • 19. False Positive Digital Mammogram Tomosynthesis Image
  • 20. Digital Mammogram Tomosynthesis Image Cancer
  • 21. ConclusionsConclusions Tomosynthesis previously shown to improveTomosynthesis previously shown to improve radiologist performance: 3D+2D compared toradiologist performance: 3D+2D compared to 2D2D Variability of AUROC reduced when using 3D,Variability of AUROC reduced when using 3D, for cases not involving calcifications, p = 0.02for cases not involving calcifications, p = 0.02 Variability unchanged for calc casesVariability unchanged for calc cases Radiologists are more accurate (AUROC) andRadiologists are more accurate (AUROC) and more confident (Variances) with 3D+2D,more confident (Variances) with 3D+2D, compared to 2D for mass detectioncompared to 2D for mass detection Radiologists agreed more often on decision toRadiologists agreed more often on decision to recall nonrecall non--cancercancer cases with 2D+3D than 2Dcases with 2D+3D than 2D
  • 22. More on the same subjectMore on the same subject…… Elizabeth Rafferty, MDElizabeth Rafferty, MD Massachusetts General Hospital, Boston MA, USAMassachusetts General Hospital, Boston MA, USA InterInter--reader variability: Comparing breastreader variability: Comparing breast tomosynthesis combined with FFDM to FFDM alonetomosynthesis combined with FFDM to FFDM alone Multi-center, retrospective study: Comparing breast tomosynthesis combined with FFDM to FFDM alone Sunday, March 8, 14:00-15:30 Satellite Symposium, Room F2
  • 23. Thank youThank you Images and data courtesy of:Images and data courtesy of: •• Massachusetts General Hospital, Boston MA USAMassachusetts General Hospital, Boston MA USA •• Netherlands Cancer InstituteNetherlands Cancer Institute –– AntoniAntoni Van Leeuwenhoek Hospital, Amsterdam HollandVan Leeuwenhoek Hospital, Amsterdam Holland •• Centre deCentre de RadiologieRadiologie etet dd’’EchographieEchographie dudu DocteurDocteur JoussierJoussier, Paris France, Paris France •• Dartmouth Hitchcock Medical Center, Lebanon NH USADartmouth Hitchcock Medical Center, Lebanon NH USA •• Magee WomenMagee Women’’s Hospital, Pittsburgh PA USAs Hospital, Pittsburgh PA USA •• University of Iowa Health Care, Iowa City IA USAUniversity of Iowa Health Care, Iowa City IA USA •• Yale University School of Medicine, New Haven CT USAYale University School of Medicine, New Haven CT USA