Strengths of tomosynthesis could hinder its adoption

While radiologists herald breast tomosynthesis as the hope for the future of breast imaging, several barriers hinder its widespread use. Its very ability to detect benign lesions dilutes the value of such detection, according to a keynote speech at the RSNA meeting.

Radiologists hope breast tomosynthesis will improve sensitivity in detection of breast cancer by removing overlapping structures and improving the conspicuity of breast lesions, said Dr. Jay Baker, director of breast imaging at Duke University, during his keynote speech on Tuesday.

"Tomosynthesis may also improve the specificity by allowing better evaluation of lesion morphology and the ability to recognize benign lesions for what they are," he said.

While detecting lesions is the strength of tomosynthesis, however, it may also be the modality's biggest weakness.

"We end up seeing every fibroid adenoma and every cyst when we markedly increase our detection of otherwise benign lesions," he said.

Increasing the number of detected benign lesions becomes problematic because, ultimately, the detection does not aid the patient. The hope that tomosynthesis will reduce the overall number of recalls depends on clarifying architectural distortion, which on diagnostic examination turns out to be nothing more than overlapping but normal breast tissue, Baker said.

"It's also possible that tomosynthesis may allow us to reduce the number of benign biopsies by allowing better evaluation of lesion morphology. But in order to do this, it would require an entirely new imaging paradigm than what we're presently used to," he said.

Tomosynthesis may move to a point at which, if a radiologist identifies a round, oval, or lobulated mass that is 100% circumscribed, the radiologist may simply declare the lesion benign.

This may, however, ultimately lead to a delay in diagnosis, he said.

"Obviously, we're not there yet. We don't have the data to suggest this. We may need to get to this point in order for breast tomosynthesis to live up to its ultimate promise," he said.

Two more pressing challenges to tomosynthesis' introduction are lack of FDA-approved systems in the U.S. and a dearth of published data, according to Baker.