Increased microcalcification visibility in lumpectomy specimens

using a stationary digital breast tomosynthesis system

Andrew W Tucker*, Yueh Z Lee, Cherie M Kuzmiak, Jabari Calliste, Jianping Lu, and Otto
Zhou
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

ABSTRACT

Current digital breast tomosynthesis (DBT) systems have been shown to have diminished microcalcification (MC)
visibility compared to 2D mammography systems. Rotating gantry DBT systems require mechanical motion of the
X-ray source which causes motion blurring of the focal spot, thus reducing spatial resolution. We have developed a
stationary DBT (s-DBT) technology that uses a carbon nanotube (CNT) based X-ray source array in order to acquire
all the projections images without any mechanical motion. It is capable of producing full tomosynthesis datasets
with zero motion blur. It has been shown to have significantly higher spatial resolution than continuous motion
DBT systems. An s-DBT system also allows for a wider angular span without increasing the acquisition time. A
larger angular span covers a larger portion of the Fourier domain, thus decreasing the tissue overlap. In this study,
we compare tomosynthesis imaging of MCs, in lumpectomy specimens, between an s-DBT system and a rotating
gantry DBT system. Results show that s-DBT produces better MC sharpness and reduced tissue overlap compared
to continuous motion DBT systems.

Key Words: Mammography, Digital breast tomosynthesis, CNT X-ray, Specimen imaging, High resolution

1. INTRODUCTION

Microcalcifications (MCs) are helpful in breast cancer diagnosis for malignancy determination. Characteristics such
as size, distribution, morphology, and variability of the MCs help in the assessment 1, 2. Some MCs can be less than
100 µm in diameter, so high spatial resolution is needed in mammography for their visualization. Full-field digital
mammography (FFDM) systems, the current gold standard for screening mammography, have no z-axis information
which results in tissue overlap in the images. This leads to high false positive and false negative rates3, 4. Digital
breast tomosynthesis (DBT) is capable of reducing tissue overlap by using a small number of angular projection
images.

Current DBT systems have been shown to have better sensitivity and specificity for breast masses compared to
FFDM5, 6. However, current DBT systems acquire projection images by moving a single X-ray source over the
angular span. This motion blurs the focal spot thus reducing the spatial resolution of the system which leads to
reduced MC visibility compared to FFDM6. The Selenia Dimensions DBT system (Hologic Inc., Bedford, MA)
acquires DBT datasets in a continuous motion mode. Since FDA approval of the Selenia Dimensions in early 2011
for combination (combo) mode (DBT plus FFDM) screening examinations, a large number of single site studies
have been reported on the Selenia Dimensions showing the improved sensitivity and specificity of the system over a
2D imaging modality5-7. The sensitivity and specificity improvement was shown for cases with breast masses.
However, for cases with MCs, the use of the combo mode has shown no improvement in the area under the curve
when compared with FFDM imaging alone6. The added FFDM image in combo mode allows for visualization of
MCs but still lacks z-axis resolution and doubles the dose to the patient.

*awtucker@ncsu.edu; phone 1-704-614-2640; http://research.physics.unc.edu/project/zhou/

Medical Imaging 2014: Physics of Medical Imaging, edited by Bruce R. Whiting, Christoph Hoeschen, Despina Kontos,
Proc. of SPIE Vol. 9033, 903316 · © 2014 SPIE · CCC code: 1605-7422/14/$18 · doi: 10.1117/12.2043522

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 A stationary digital breast tomosynthesis (s-DBT) system uses a carbon nanotube (CNT) based X-ray source array
in order to acquire a full DBT acquisition with zero source motion blur8, 9. The spatial resolution of s-DBT has been
shown to be significantly higher than continuous motion DBT systems10. Higher spatial resolution should allow for
better visualization of MCs. In s-DBT, a larger angular span can be acquired without an increase in acquisition
time. Larger angular spans cover a larger portion of the Fourier domain, thus decreasing the tissue overlap present
in the reconstruction images. In this study, we demonstrate improved visibility of MCs, in human tissue, using an s-
DBT system compared to the Selenia Dimensions DBT system.

2. METHODS

2.1 s-DBT system

The CNT X-ray source array (XinRay Systems LLC, Research Triangle Park, NC) is mounted on a Hologic Selenia
Dimensions DBT system (Hologic Inc., Bedford, MA). The system consists of 31 individual focal spots distributed
in a linear array over a 30 degree span that can be operated at up to 45 kVp10. The system uses a tungsten anode
with a 1.0 mm thick aluminum filter and a 700 mm source-to-imager distance (SID). Breast surgical specimen
images were collected using 15 projection images over a 28 degree span and a detector pixel size of 0.07 mm. A 26
kVp tube potential was used with 100 mAs tube exposure for each specimen. Figure 1 (Left) shows the s-DBT
system after integration with the CNT X-ray source.

The measured system modulation transfer function (MTF) of the s-DBT system is 5.15 cycles/mm at 10% (using the
full resolution of the detector), which is significantly higher than the value measured on a continuous motion DBT
system (2.8 cycles/mm)9, 10.

Figure 1: Left - Image of the s-DBT system with integrated CNT based X-ray source array. The arrow points to the source
array. Right - Image of the Selenia Dimensions DBT system in our lab.

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 2.2 Continuous motion DBT system

A Hologic Selenia Dimensions DBT system (Hologic Inc., Bedford, MA) was used as the continuous motion DBT
system11. Figure 1 (Right) shows an image of the Selenia Dimensions in our lab. The system uses a tungsten anode
with a 0.7 mm thick aluminum filter and a 700 mm SID. The s-DBT system was modeled after the Selenia
Dimensions but uses a 1 mm thick aluminum filter instead. Lumpectomy images on the Selenia Dimensions were
collected using 15 projection images over an angular span of 15 degrees and a detector pixel size of 0.14 mm. The
same tube potential and exposure were used for the Selenia Dimensions as the s-DBT system (26 kVp, 100 mAs).

2.3 Specimen retrieval and imaging

Under an institutional review board approved protocol, 23 patients with known breast lesions (BIRADS 4 or 5) and
who were scheduled for a pre-operative needle localization for open surgical biopsy were recruited. Once the
procedure was completed the specimen was picked up from the operating room and transported it to the Department
of Radiology for imaging. Hospital protocol requires a magnified 2D FFDM image for each specimen in order to
assess removal of the localized lesion and surgical margins. After imaging was completed, the specimen was
transported to our imaging facility where it was imaged on an s-DBT system and a Selenia Dimensions system. The
specimen was then returned to the Department of Pathology for histologic evaluation. A one hour time frame was
adhered to from excision time in the operating room to specimen return in Pathology.

All surgical specimens were imaged in a quasi-radiolucent specimen container. Figure 2 (Left) shows an image of
the specimen container on the s-DBT system. Once the breast specimen was place in a container by the surgeon it
was gently compressed with a perforated labeled grid. A 2D FFDM of the grid can be seen in Figure 2 (Right).

6
The grid is used for localization of lesions in the specimen for the Department of Pathology.

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Figure 2: (Left) - Image of a specimen container on the s-DBT system. The arrow points to the container. (Right) - A 2D
FFDM of one of the specimen containers showing the perforated grid.

2.4 Reconstructions

Image reconstruction for both systems was completed with a dynamic 3D image reconstruction software package
developed by Real Time Tomography, LLC (Villanova, PA). This software uses a back projection filtering method
to reconstruct the pseudo-3D volume from the projection images12. Images were reconstructed with a pixel size

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 equivalent to a 1.8x magnification (a 1.8x radiographic magnification is used in specimen radiography). Figure 3
shows an s-DBT reconstruction slice of a lumpectomy specimen.

Figure 3: An s-DBT reconstruction slice of a lumpectomy specimen. Guide wires and surgical clips were present in most
specimen images.

2.5 MC selection

All breast surgical specimen image datasets were analyzed for isolated MCs that were visible in both imaging
modalities and that were not in the vicinity of other objects (other MCs or guide wires). Twelve isolated MCs were
selected in five different specimens for further analysis. Visually, the in-focus plane was determined. The
sharpness of each MC was analyzed in both the x-y plane and the z-axis. An MC area estimate was used for x-y
plane, and the artifact spread function (ASF) was used for the z-axis.

2.6 X-Y plane sharpness

A small region of interest (ROI) was selected around each MC that was analyzed. A threshold value of 50%
between the maximum and minimum pixel intensity value, for the ROI, was set. Pixels above this threshold value
were segmented and determined to be contained in the MC. Area estimates were made by multiplying the
reconstruction pixel size by the number of pixels contained in the MC. The area estimate of the MC was used as the
figure of merit for x-y plane sharpness.

2.7 Z-axis sharpness

Using the same ROI and segmented area as above (Section 2.6), the ASF was calculated for each MC. The ASF is a
figure of merit which evaluates the out of plane blurring effect in tomosynthesis reconstructions 4. The equation for
ASF in reconstruction plane "z" can be found below:

(1)

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 where "SA" is the average pixel intensity in the segmented region, "SB" is the average pixel intensity in the
background region, and "zo" is the plane of reconstruction where the MC is in focus. The full width at half
maximum (FWHM) of the ASF was used as the figure of merit for z-axis sharpness.

3. RESULTS

3.1 Image Comparison

Figure 4 shows reconstruction slices of a breast specimen using the s-DBT system and the continuous motion DBT
system. Zoomed in regions of interest (Figure 4-Below) clearly show the increased image sharpness in the s-DBT
system. In the s-DBT image, MCs are not "blurred" together as in the continuous motion DBT image. The
increased angular coverage in the s-DBT system removes artifacts from out-of-plane MCs making delineation more
accurate.

Figure 4: Reconstruction slice of a specimen with a large cluster of MCs using the s-DBT system (Top-Left) and the continuous
motion DBT system (Top-Right). MC sharpness is superior in the zoomed in s-DBT reconstruction (Bottom-Left) compared to
the continuous motion DBT system (Bottom-Right).

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 3.2 X-Y plane sharpness

Results for each MC size can be found in Table 1. A smaller area was found for every MC using the s-DBT
system. The average decrease in area for s-DBT was 28.92 ±12.60%. This can be attributed to the higher spatial
resolution of s-DBT compared to continuous motion DBT systems. Figure 5 shows visual comparison between the
two systems for six of the MCs. Based on the MC area calculation and the visual comparison in this study, it can be
determined that s-DBT has improved x-y plane sharpness than continuous motion DBT.

Table 1: Results of the MC area calculation and the FWHM of the ASF. Results show that for every MC analyzed, s-DBT
outperformed the continuous motion DBT system in localization of the MCs in the x, y, and z directions.

Percent FWHM FWHM

MC s-DBT DBT
Area of ASF of ASF -
case Area Area
Decrease - s-DBT DBT
Number (mm2) (mm2)
for s-DBT (mm) (mm)
1 3.6 4.09 11.98 3.5 5
2 2.33 3.66 36.34 2.5 4.5
3 2.79 3.05 8.52 2 4
4 1.69 2.79 39.43 1.5 5
5 1.74 3.08 43.51 1.5 4
6 2.96 3.59 17.55 2.5 4
7 1.7 2.74 37.96 1.5 3.5
8 2.21 3.69 40.11 1.5 4
9 2.1 3.69 43.09 2.5 4
10 2.43 3.21 24.30 3.5 4.5
11 2.5 3.1 19.35 3.5 5
12 2.82 3.76 25.00 2.5 5

MC 1 MC 2 MC 3 MC 4 MC 5 MC 6

Figure 5: Zoomed in ROIs of the first 6 MCs. The row above contains the s-DBT reconstruction images, while the row below
contains the continuous motion DBT system reconstruction images.

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 3.3 Z-axis sharpness

Figure 6 shows the ASF of s-DBT and continuous motion DBT for MC number 6. For this MC, the FWHM was
found to be 2.5 mm for s-DBT and 4 mm for DBT. Table 1 shows all results for the 12 MCs. The s-DBT system
reduced the ASF width by an average of 2.00±0.67 mm. From the data it can be seen that s-DBT has better z-axis
sharpness than continuous motion DBT.

ASF: s-DBT vs. Continuous Motion DBT

Normalized Average Intensity

1
s-DBT
Continous Motion DBT
0.8

0.6

0.4

0.2

0
-3 -2 -1 0 1 2 3
Distance from Plane of Focus (mm)
Figure 6: Plot of the ASF for s-DBT and continuous motion DBT for MC number 6. The larger angular coverage of the s-DBT
system reduces out-of-plane reconstruction artifacts.

4. DISCUSSION AND CONCLUSION

This work demonstrates that an s-DBT system can produce increased microcalcification sharpness in human breast
tissue compared to a Selenia Dimensions DBT system. Increased MC sharpness leads to increased MC visibility,
which is apparent in Figure 4 and Figure 5. Increased MC sharpness was shown for every MC that was analyzed.

Increased sharpness in the x-y plane of an s-DBT reconstruction slice comes from the decreased size of the effective
focal spot. In a continuous motion DBT system, such as the Selenia Dimensions, the focal spot is blurred during
image acquisition. The blurring of the focal spot increases the effective focal spot size of the system. Consequently,
increasing the exposure of an image acquisition further increases the effective focal spot size by increasing the
amount of X-ray tube travel time. An s-DBT system has no focal spot blur. Therefore, the effective focal spot size
is equal to the focal spot size times the focal spot enlargement factor (as with all X-ray imaging systems).
Increasing the exposure of an image acquisition does not change the effective focal spot size, only the acquisition
time. This is consistent with previous phantom studies that show an increase in the value of the MTF for s-DBT9, 10.

As the angular span of a single source DBT system increases so does the z-axis sharpness and the total acquisition
time. Long acquisition times in mammography leads to patient motion which can decrease image sharpness. The
effect of patient motion on image sharpness can be more dramatic than the focal spot blurring of continuous motion
DBT systems13. An s-DBT system is capable of using larger angular spans with zero increase in image acquisition
time. The increased z-axis sharpness in s-DBT not only increases MC visibility but also further decreases tissue
overlap. A large angular span gives better coverage of the Fourier domain, which is the underlying reason behind
the increased MC visibility and decreased tissue overlap.

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 We reported the first comparison of an s-DBT system with a continuous motion DBT system using human breast
tissue. It has been shown that s-DBT is capable of producing higher MC sharpness in the x, y, and z directions.
MCs ranging in measured in-plane area from 1.69 to 3.6 mm2 had an average decrease in area of 28.92±12.60% and
an average decrease in ASF width of 2.00±0.67 mm when imaged on the s-DBT system compared to the Selenia
Dimensions. The higher sharpness of s-DBT reconstructions could produce higher area under the curve values for
screening patients with MCs. This study was conducted without the focusing voltage of the s-DBT system on. A
further increase in sharpness is expected with the focusing electrodes engaged.

5. ACKNOWLEDGEMENT

The project is supported by the National Cancer Institute under grant number U54CA119343. We would like to
thank Hologic for providing the Selenia Dimension tomosynthesis system and for technical support. Thanks to
Emily Gidcumb, Christy Inscoe, Jing Shan, and Marci Potuzko for support in acquiring image datasets.

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