· Tomosynthesis: Next-Generation Breast Cancer Exam
· X-Rays in the Digital Age
· Worth the Long Weight

Tomosynthesis: Next-Generation Breast Cancer Exam

Digital tomosynthesis is new, but it is already getting noticed as the next-generation breast cancer exam. The modality, which captures multiple x-ray pictures of the breast from multiple angles, is not limited by tumor-blocking anatomical structures that present a challenge in mammography.

“Digital breast tomosynthesis is a new three-dimensional technique that is showing clear evidence in overcoming this limitation. Further studies are in progress, but tomosynthesis will have an important role to play in the future of breast care and is likely to replace mammography,” said Dr Ingvar Andersson from the department of diagnostic radiology at the University Hospital of Malm? in Sweden, in a press release.

Digital tomosynthesis addresses some of the biggest challenges in mammography: decreased visualization of tumors due to overlapping tissue, the limited number of views, and patient discomfort. The technology takes advantage of advances in digital detectors that enable the acquisition of low-dose images with high efficiency, fast readouts, and minimal image lag.

Tomosythesis captures low-dose images—11 images over 7 seconds—from different angles and reconstructs the slices for an image that offers greater detail than conventional mammography. The breast is positioned the same way as in mammography, but much less pressure is applied. Less pain may translate to increased compliance with screening recommendations, resulting in earlier diagnoses and better outcomes.

The Abstract

The research is promising, suggesting that better visualization may also help to improve outcomes. Early results from clinical trials under way by Andersson’s group at the University Hospital of Malm? support tomography as a more effective technique in the earlier detection of breast cancer when compared to conventional and digital mammography.

The research team evaluated a group of breast cancer patients who were selected based on the difficulty of their 2D mammography exams. The visibility of breast tumors on digital mammography and tomography was then graded, and findings were classified according to the Breast Imaging Reporting and Data System. “The results suggest that Tomosynthesis is a more sensitive technique for the detection of breast cancer than conventional digital mammography,” the team writes on its Web site.

However, further studies are needed before the modality will be approved for use in the United States, and some are already under way. UK clinical trials of tomosynthesis are expected to be announced soon and to present findings similar to those of earlier research. In the meantime, manufacturers are working on tomosythesis capabilities. The Mammomat Inspiration, available in the United Kingdom from Siemens Medical Solutions, Malvern, Pa, will be able to add tomosynthesis capabilities with a simple upgrade.

“Simply put, this technology advancement enables us to virtually slice up the breast to look inside and explore in-depth. Earlier detection of lesions can mean less invasive treatments,” said Samantha Smith, women’s health specialist at Siemens Healthcare. “Despite the great success rates of breast cancer detection initiatives across the world, tomosynthesis offers another step forward in this area to improve survival rates further and detect cancers earlier.”

—Renee Diiulio

X-Rays in the Digital Age

X-ray exams continue to be the most commonly used modality. They are a simple, cost-effective, and well-established means of diagnosis and planning, and allow accurate diagnoses for a wide range of conditions and diseases,” said Todd R. Minnigh, worldwide director of marketing for digital radiography at Carestream Health Inc, based in Rochester, NY.

Carestream’s new DRX-1 system will launch in 2009 and features a wireless cassette-size detector.

To stay relevant in the digital age, x-ray systems have gone digital themselves. Today’s systems, both CR and DR, offer improved image quality and features that help automate positioning and image capture. Clinicians are able to make diagnoses with greater rapidity, accuracy, and confidence than with previous generations of machines. PACS systems increase image access not only to mobile physicians but also to specialists and remote clinicians.

“When combined with PACS, these digital imaging exams offer enhanced diagnostic tools that help radiologists and other clinicians view and measure anatomical structures and detect changes in a patient’s condition when compared to previous exams,” Minnigh said.

These improvements have come in both hardware and software, and include dual-detector DR systems; advances in image processing that control brightness, latitude, and detail contrast; new calibration tools; and improvements in reporting. “The goal of most new features and tools is to improve patient care by simplifying operations and improving productivity for all clinical users. Modern DR systems expedite patient positioning and image capture by technologists,” Minnigh said. In other words, they make x-rays faster, clearer, handier, safer, and more affordable.


DR systems have gotten faster and image access more reliably, according to Frana Evans, BS, RT (R), director of radiology at Springfield Clinic in Springfield, Ill. “Springfield Clinic physicians gain image access via the clinic’s secure network using any computer with Internet access,” Evans said.

The physician-owned Springfield Clinic includes 20 facilities serving approximately 200 physicians and surgeons. These physicians and other staff appreciate the speed and convenience that result from digital imaging. What’s more, surgeons appreciate the ease of templating images for joint-replacement surgeries.


“The newest generation of software processing is also a key area for productivity gains,” Minnigh said, citing examples:

  • New software for Carestream Health’s CR and DR platforms can render images without technologists having to identify the body part or projection information.
  • The IHE consistent presentation of images profile on modalities and viewing workstations can be leveraged to achieve more consistent image presentation across multiple viewing platforms and devices. This supports functionality to send annotations and markers as an overlay on an image, and ensures that images are rendered consistently on different workstations.
  • Digital planning and templating software offer more accurate presurgical planning for joint replacements, “a burgeoning procedure for the aging population,” Minnigh says.


As the software systems have improved, so has the hardware. “Single- or dual-detector configurations with an upright floor-mounted stand and table offer much greater flexibility than ever before,” Minnigh said. Automated long-length imaging is now available on major DR platforms. Accessories make these systems even handier.

  • Fixed, elevating tables are ideal for detailed imaging studies, such as those conducted before and after spine surgery.
  • New wall-stand buckys offer side-to-side swing features and three-axis movement that simplify patient positioning as well as traditionally difficult exams, such as cross-table laterals.
  • Preprogrammed exams, auto-centering features, detector movement tracking, and the ability to achieve consistent source-to-detector alignment save time.


Digital imaging systems also have the added benefit of built-in backup methods. “With digital imaging there is a backup system rather than one set of ?original’ film,” Evans said.

Improved security measures mean more secure transmissions and therefore a greater ability and confidence in sending them. Images can be sent to multiple physicians, specialists, and hospitals quickly, permitting simultaneous reviews.

“DR systems offer facilities ease of access for staff and physicians, more security, and less liability for lost images due to PACS storage and electronic disaster recovery,” Evans said.

More Affordable

As next-generation systems have debuted, costs have come down, resulting in better systems that have greater value than in the past. “Since the exams are completed so quickly, DR technology results in increased exam productivity and efficiencies and provides the staff with the ability to do more exams with less equipment,” Evans said.

“Many imaging decisions ultimately come down to cost and convenience,” Minnigh said. Subsequently, cost can be a driver for new developments. For instance, Carestream expects to launch in the first quarter of 2009 a wireless, cassette-size detector, the Carestream DRX-1 System, which can be easily incorporated into all types of radiology environments without modifications of existing rooms.

Increased capabilities for imaging can result in improved outcomes and increased revenues, and Minnigh expects that advances in image quality, speed, and flexibility will dominate the x-ray space for some time.

—R. Diiulio

Worth the Long Weight

It’s a simple geometric principle: If one knows a point in space in one plane and the same point in another plane, the individual knows the point in 3D space.

Applying this basic concept to its technology, Biospacemed, Atlanta, has released its EOS x-ray imager for use along with its new image workstation, sterEOS. The system enables 3D surface rendering consisting of skeletal anatomy from only two simultaneously taken low-dose images.

“The simultaneous biplane acquisition creates two images whose location in space is known by the computer,” explained Richard diMonda, clinical development consultant.

“From this physical structure of the imager, the computer can then create the 3D imager.”

Particularly ideal for spine pathologies and hip and knee arthropathies, EOS can capture head-to-toe images of patients in a standing, weight-bearing position. According to the company, the technology uses 10 times less radiation dosage than a conventional x-ray and up to 1,000 times less radiation dosage than a CT scan.

“EOS is especially helpful in any situation where patients want to limit their exposure to radiation, and also in situations where long-length, weight-bearing images are needed,” said Jean-Charles LeHuec, MD, PhD, Bordeaux Spine Center, Pellegrin University Hospital, France. “The full-length, weight-bearing imaging capabilities of EOS are able to provide physicians with a global assessment of balance and posture, and now, with 3D, an assessment of the relative positioning of each vertebra, thereby enabling better preoperative assessment.”

diMonda said the imager allows physicians to evaluate vertebral rotation, which is difficult to assess from a planar image. Because measurements are not calculated directly from the image, but rather from within the 3D space, they are more accurate and reproducible, diMonda said. “A patient can become their own ‘reference frame’ so that measurements are more comparable over time,” he continued. Additionally, the EOS can image 10 to 12 patients per hour, which is about five times faster than ordinary long-length imaging systems, according to the company?s calculations.

“We think that this technology could become a new standard of care for orthopedic surgeons because it enables new information and accuracy to contribute to the surgical planning process and thereby hopefully improve outcomes,” diMonda said. “We are beginning to research this but already have some interesting examples of how long-length images and 3D-related measurements can make a very helpful contribution.”

—Elaine Sanchez