The development of screening mammography over 30 years has remarkedly reduced breast cancer–associated mortality by 20%-30% through detection of small cancer lesions at early stages. Yet breast screening programmes may function differently in each nation depending on the incidence rate, national legislation, local health infrastructure and training opportunities including feedback on performance. Mammography has been the frontline breast cancer screening tool for several decades; however, it is estimated that there are 15% to 35% of cancers missed on screening which are owing to perceptual and decision-making errors by radiologists and other readers. Furthermore, mammography screening is not available in all countries and the increased speed in the number of new breast cancer cases among less developed countries exceeds that of the developed world in recent decades. Studies conducted through the BreastScreen Reader Assessment Strategy (BREAST) training tools for breast screening readers have documented benchmarking and significant variation in diagnostic performances in screening mammogram test sets in different countries. The performance of the radiologists from less well-established breast screening countries such as China, Mongolia and Vietnam were significant lower in detecting early-stage cancers than radiologists from developed countries such as Australia, USA, Singapore, Italy. Differences in breast features and cancer presentations, discrepancies in the level of experiences in reading screening mammograms, the availability of high-quality national breast screening program and breast image interpretation training courses between developed and less developed countries are likely to have impact on the variation of readers’ performances. Hence dedicated education training programs with the ability to tailor to different reader cohorts and different population presentations are suggested to ameliorate challenges in exposure to a range of cancer cases and improve the interpretation skills of local radiologists. Findings from this review provide a good understanding of the radiologist’ performances and their improvement using the education interventions, primarily the BREAST program, which has been deployed in a large range of developing and developed countries in the last decade. Self-testing and immediate feedback loops have been shown to have important implications for benchmarking and improving the diagnostic accuracy in radiology worldwide for better breast cancer control.

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Look how far we have come: BREAST cancer detection education on the international stage

PURPOSE The SYRMA-3D collaboration is setting up a breast computed tomography (bCT) clinical program at the Elettra synchrotron radiation facility in Trieste, Italy. Unlike the few dedicated scanners available at hospitals, synchrotron radiation bCT requires the patient's rotation, which in turn implies a long scan duration (from tens of seconds to few minutes). At the same time, it allows the achievement of high spatial resolution. These features make synchrotron radiation bCT prone to motion artifacts. This article aims at assessing and compensating for motion artifacts through an optical tracking approach. METHODS In this study, patients' movements due to breathing have been first assessed on seven volunteers and then simulated during the CT scans of a breast phantom and a surgical specimen, by adding a periodic oscillatory motion (constant speed, 1 mm amplitude, 12 cycles/minute). CT scans were carried out at 28 keV with a mean glandular dose of 5 mGy. Motion artifacts were evaluated and a correction algorithm based on the optical tracking of fiducial marks was introduced. A quantitative analysis based on the structural similarity (SSIM) index and the normalized mean square error (nMSE) was performed on the reconstructed CT images. RESULTS CT images reconstructed through the optical tracking procedure were found to be as good as the motionless reference image. Moreover, the analysis of SSIM and nMSE demonstrated that an uncorrected motion of the order of the system's point spread function (around 0.1 mm in the present case) can be tolerated. CONCLUSIONS Results suggest that a motion correction procedure based on an optical tracking system would be beneficial in synchrotron radiation bCT.

Motion artifacts assessment and correction using optical tracking in synchrotron radiation breast CT.

OBJECTIVES
To design a device that can support the breast during phase-contrast tomography, and characterise its fit parameterisation and comfort rating.


METHODS
Twenty-seven participants were recruited to trial a system for breast support during simulated Phase contrast imaging, including being positioned on a prone imaging table while wearing the device. Participants underwent a photogrammetry analysis to establish the geometric parameterisations. All participants trialled a single-cup design while 14 participants also trialled a double-cup with suction holder and all completed a series of questionnaires to understand subjective comfort.


RESULTS
Photogrammetry revealed significant positive correlations between bra cup volume and measured prone volume (p < 0.001), and between "best fit" single-cup holder volume and measured prone volume (p < 0.005). Both holders were suitable devices in terms of subjective comfort and immobilisation while stationary. However, some re-engineering to allow for quick, easy fitting in future trials where rotation through the radiation beam will occur is necessary. Light suction was well-tolerated when required.


CONCLUSIONS
All participants indicated the table and breast support devices were comfortable, and they would continue in the trial.


ADVANCES IN KNOWLEDGE
Phase contrast tomography is an emerging breast imaging modality and clinical trials are commencing internationally. This paper describes the biomedical engineering designs, in parallel with optimal imaging, that are necessary to measure breast volume so that adequate breast support can be achieved. Breast support devices have implications for comfort, motion correction and maximising breast tissue visualisation.

Designing a breast support device for phase contrast tomographic imaging: getting ready for a clinical trial.

Purpose: This study aims at establishing the optimum x-ray energy for synchrotron acquired propagation-based computed tomography (PB-CT) images to obtain highest radiological image quality of breast mastectomy samples. It also examines the correlation between objective physical measures of image quality with subjective human observer scores to model factors impacting visual determinants of image quality. Approach: Thirty mastectomy samples were scanned at Australian Synchrotron’s Imaging and Medical Beamline. Samples were scanned at energies of 26, 28, 30, 32, 34, and 60 keV at a standard dose of 4mGy. Objective physical measures of image quality were assessed using signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), SNR/resolution (SNR/res), CNR/resolution (CNR/res) and visibility. Additional calculations for each measure were performed against reference absorption-based computer tomography (AB-CT) images scanned at 32 keV and 4mGy. This included differences in SNR (dSNR), CNR (dCNR), SNR/res (dSNR/res), CNR/res (dCNR/res), and visibility (dVis). Physical measures of image quality were also compared with visual grading analysis data to determine a correlation between observer scores and objective metrics. Results: For dSNR, dCNR, dSNR/res, dCNR/res, and dVis, a statistically significant difference was found between the energy levels. The peak x-ray energy for dSNR and dSNR/res was 60 keV. For dCNR and dCNR/res 34 keV produced the highest measure compared to 28 keV for dVis. Visibility and CNR correlate to 56.8% of observer scores. Conclusion: The optimal x-ray energy differs for different objective measures of image quality with 30-34 keV providing optimum image quality for breast PB-CT. Visibility and CNR correlate highest to medical imaging expert scores.

Energy optimisation of propagation-based phase-contrast computed tomography: a quantitative image quality assessment

Multiscale X-ray phase-contrast tomography: From breast CT to micro-CT for virtual histology.

Aim: In recent years Phase Contrast Tomography (PCT) has been rapidly progressing towards clinical translation as an advanced imaging technology for breast cancer diagnosis. Recent optimization of PCT with mastectomy samples has refined imaging protocols and biomedical-engineering prowess is now required to formalize patient table and breast immobilisation requirements. PCT imaging requires women to lie in prone position similar to conventional breast CT, however the imaging couch rotates above the beam allowing exposure of the breast beneath. Motion artefact through involuntary movement of the breast through the rotation cycle has the potential to reduce diagnostic quality of the results. Methods: This paper details the biomedical engineering cycle of breast holder development alongside medical physics considerations. Breast immobilisation via a plastic or silicone supporting material which is sufficiently transparent for X-rays in the targeted energy range is explained, including the two step process of considering single cup versus double cup solutions and how mild-suction to the breast can be implemented in order to maximum breast tissue visualization and assist with dose uniformity. Results: Considering patient comfort, breast positioning and implications upon attenuation and phase shift, a number of models were developed in Australia and Italy. Early prototypes are described here with some preliminary imaging. Considerable work is taking place over the next three months as models undergo imaging with mastectomy samples at the Imaging and Medical Beamline at the Australian Synchrotron and the ELETTRA Synchrotron Italy. Consumer representatives will be rating the immobilisation device for comfort prior to the start of clinical trials in 2020.

Nathan Tam

Papers

Getting a-breast of immobilisation needs for the implementation of phase contrast tomography

Designing a breast support device for phase contrast tomographic imaging: getting ready for a clinical trial.