OBJECTIVE. The primary objectives of this pilot study were to evaluate the radiation dose, breast coverage, and image quality of cone-beam breast CT compared with a conventional mammographic examination. Image quality analysis was focused on the concordance of cone-beam breast CT with conventional mammography in terms of mammographic findings.SUBJECTS AND METHODS. This prospective study was performed from July 2006 through August 2008. Twenty-three women were enrolled who met the inclusion criteria, which were age 40 years or older with final BI-RADS assessment category 1 or 2 lesions on conventional mammograms within the previous 6 months. The breasts were imaged with a flat-panel detector-based cone-beam CT system, and the images were reviewed with a 3D visualization system. Cone-beam breast CT image data sets and the corresponding mammograms were reviewed by three qualified mammographers. The parameters assessed and compared in this pilot study were radiation dose, breast tissue coverage, and image qua...

https://www.ajronline.org/doi/pdf/10.2214/AJR.08.1017

Cone-Beam CT for Breast Imaging: Radiation Dose, Breast Coverage, and Image Quality

Spectral CT systems with photon counting detectors have more advantages compared to conventional CT systems. However, clinical applications have been hampered for a long time due to the high demands of clinical systems and limitations of spectroscopic x-ray detectors. Photon counting detector technology has gained considerable improvements in the past decade, and spectral CT has become a hot topic. Several experimental spectral CT systems are under investigation. The purpose of this work was to perform the first direct, side-by-side comparison of existing spectral CT technology with a mature clinical CT system based on a conventional energy integrating detector. We have built an experimental spectral CT system whose main parameters are similar to the parameters of a clinical CT system. The system uses a spectroscopic cadmium zinc telluride (CZT) detector. The detector includes two rows of CZT pixels with 256 pixels in each row. The pixel size is 1 × 1 mm(2), and the maximum count rate is 2 Mcounts/pixel/s. The spectral CT system has a magnification factor of 1.62 and the source to detector and source to image distances of 85 and 53 cm, respectively. The above parameters are similar to those of the clinical CT system, Siemens Sensation 16, used for comparison. The two systems were compared by imaging spatial resolution and contrast resolution phantoms made from acrylic cylinders with 14 cm diameters. The resolution phantom included Al wires with 0.3, 0.6, and 1 mm diameters, and 0.25 g cc(-1) CaCO(3) contrast. The contrast phantom included contrast elements with 1.7, 5, and 15 mg cc(-1) iodine, and 1.1, 3.3, and 10 mg cc(-1) gadolinium. The phantoms were imaged with the two systems using 120 kVp tube voltage and 470 mR total skin exposure. The spectral CT showed CT numbers, image noise, and spatial and contrast resolutions to be similar within 10% compared to the Siemens 16 system, and provided an average of 10% higher CNR. However, the spectral CT system had a major advantage in that the iodine, gadolinium, and CaCO(3) contrasts were decomposed by dual-energy and K-edge subtraction methods using energy selective CT data acquired in a single CT scan and fixed tube voltage. It is concluded that photon counting spectral CT technology is close to feasibility for routine clinical applications. Furthermore, it is ready for some clinical applications such as dedicated breast CT which has relatively lower demands on photon counting detectors.

https://iopscience.iop.org/article/10.1088/0031-9155/56/7/001/pdf

Photon counting spectral CT versus conventional CT: comparative evaluation for breast imaging application.

Although conventional mammography is currently the best modality to detect early breast cancer, it is limited in that the recorded image represents the superposition of a three-dimensional (3D) object onto a 2D plane. Recently, two promising approaches for 3D volumetric breast imaging have been proposed, breast tomosynthesis (BT) and CT breast imaging (CTBI). To investigate possible improvements in lesion detection accuracy with either breast tomosynthesis or CT breast imaging as compared to digital mammography (DM), a computer simulation study was conducted using simulated lesions embedded into a structured 3D breast model. The computer simulation realistically modeled x-ray transport through a breast model, as well as the signal and noise propagation through a CsI based flat-panel imager. Polyenergetic x-ray spectra of Mo/Mo 28 kVp for digital mammography, Mo/Rh 28 kVp for BT, and W/Ce 50 kVp for CTBI were modeled. For the CTBI simulation, the intensity of the x-ray spectra for each projection view was determined so as to provide a total average glandular dose of 4 mGy, which is approximately equivalent to that given in conventional two-view screening mammography. The same total dose was modeled for both the DM and BT simulations. Irregular lesions were simulated by using a stochastic growth algorithm providing lesions with an effective diameter of 5 mm. Breast tissue was simulated by generating an ensemble of backgrounds with a power law spectrum, with the composition of 50% fibroglandular and 50% adipose tissue. To evaluate lesion detection accuracy, a receiver operating characteristic (ROC) study was performed with five observers reading an ensemble of images for each case. The average area under the ROC curves (Az) was 0.76 for DM, 0.93 for BT, and 0.94 for CTBI. Results indicated that for the same dose, a 5 mm lesion embedded in a structured breast phantom was detected by the two volumetric breast imaging systems, BT and CTBI, with statistically significant higher confidence than with planar digital mammography, while the difference in lesion detection between BT and CTBI was not statistically significant.

A computer simulation study comparing lesion detection accuracy with digital mammography, breast tomosynthesis, and cone-beam CT breast imaging

The feasibility of computed tomography (CT) with energy-resolved x-ray detection has been investigated. A breast CT design with multi slit multi slice (MSMS) data acquisition was used for this study. The MSMS CT includes linear arrays of photon counting detectors separated by gaps. This CT configuration allows for efficient scatter rejection and 3D data acquisition. The energy-resolved CT images were simulated using a digital breast phantom and the design parameters of the proposed MSMS CT. The phantom had 14 cm diameter and 50/50 adipose/glandular composition, and included carcinoma, adipose, blood, iodine and CaCO3 as contrast elements. The x-ray technique was 90 kVp tube voltage with 660 mR skin exposure. Photon counting, charge (energy) integrating and photon energy weighting CT images were generated. The contrast-to-noise (CNR) improvement with photon energy weighting was quantified. The dual energy subtracted images of CaCO3 and iodine were generated using a single CT scan at a fixed x-ray tube voltage. The x-ray spectrum was electronically split into low- and high-energy parts by a photon counting detector. The CNR of the energy weighting CT images of carcinoma, blood, adipose, iodine, and CaCO3 was higher by a factor of 1.16, 1.20, 1.21, 1.36 and 1.35, respectively, as compared to CT with a conventional charge (energy) integrating detector. Photon energy weighting was applied to CT projections prior to dual energy subtraction and reconstruction. Photon energy weighting improved the CNR in dual energy subtracted CT images of CaCO3 and iodine by a factor of 1.35 and 1.33, respectively. The combination of CNR improvements due to scatter rejection and energy weighting was in the range of 1.71–2 depending on the type of the contrast element. The tilted angle CZT detector was considered as the detector of choice. Experiments were performed to test the effect of the tilting angle on the energy spectrum. Using the CZT detector with 20° tilting angle decreased the tailing of the measured x-ray spectrum as compared to a conventional CZT detector. It was concluded that the energy-resolved MSMS CT with tilted angle CZT detector is potentially feasible and could provide a unique combination of photon counting, energy weighting, scatter rejection and single kVp dual energy subtraction CT imaging.

http://iopscience.iop.org/article/10.1088/0031-9155/53/5/020/pdf

Computed tomography with energy-resolved detection: a feasibility study.

Breast imaging is largely indicated for detection, diagnosis, and clinical management of breast cancer and for evaluation of the integrity of breast implants. In this work, a prospective view of techniques for breast cancer detection and diagnosis is provided based on an assessment of current trends. The potential role of emerging techniques that are under various stages of research and development is also addressed. It appears that the primary imaging tool for breast cancer screening in the next decade will be high-resolution, high-contrast, anatomical x-ray imaging with or without depth information. MRI and ultrasonography will have an increasingly important adjunctive role for imaging high-risk patients and women with dense breasts. Pilot studies with dedicated breast CT have demonstrated high-resolution three-dimensional imaging capabilities, but several technological barriers must be overcome before clinical adoption. Radionuclide based imaging techniques and x-ray imaging with intravenously injected contrast offer substantial potential as a diagnostic tools and for evaluation of suspicious lesions. Developing optical and electromagnetic imaging techniques hold significant potential for physiologic information and they are likely to be of most value when integrated with or adjunctively used with techniques that provide anatomic information. Experimental studies with breast specimens suggest that phase-sensitive x-ray imaging techniques can provide edge enhancement and contrast improvement but more research is needed to evaluate their potential role in clinical breast imaging. From the technological perspective, in addition to improvements within each modality, there is likely to be a trend towards multi-modality systems that combine anatomic with physiologic information. We are also likely to transition from a standardized screening, where all women undergo the same imaging exam (mammography), to selection of a screening modality or modalities based an individual-risk or other classification.

Breast cancer imaging: A perspective for the next decade

The sensitivity to detect small breast cancers and the specificity of conventional mammography (CM) remain limited owing to an overlap in the appearances of lesions and surrounding structure. We propose to address the limitations accompanying CM using flat panel detector (FPD)-based cone beam CT breast imaging (CBCTBI). The purpose of the study is to determine optimal x-ray operation ranges for different sizes of normal breasts and corresponding glandular dose levels. The current CBCT prototype consists of a modified GE HighSpeed Advantage CT gantry, an x-ray tube, a Varian PaxScan 4030CB FPD, a CT table and a PC. Two uncompressed breast phantoms, with the diameters of 10.8 and 13.8 cm, consist of three inserts: a layer of silicone jell simulating a background structure, a lucite plate on which five simulated carcinomas are mounted, and a plate on which six calcifications are attached. With a single scan, 300 projections were acquired for all phantom scans. The optimal x-ray techniques for different phantom sizes were determined. The total mean glandular doses for different size phantoms were measured using a CT pencil ionization chamber. With the optimal x-ray techniques that result in the maximal dose efficiency for the different tissue thickness, the image quality with two different phantoms was evaluated. The results demonstrate that the CBCTBI can detect a few millimeter-size simulated carcinoma and ~ 0.2 mm calcification with clinically acceptable mean glandular doses for different size breasts.

Evaluation of flat panel detector cone beam CT breast imaging with different sizes of breast phantoms

The purpose of the study is to characterize the imaging performance of the recently built novel cone beam breast CT (CBBCT) scanner. This CBBCT scanner system has one x-ray source and one flat panel detector (Varian's PaxScan 4030CB) mounted on a rotating assembly. A patient table is mounted above the rotating tube/detector assembly. The table has a hole through it that allows a woman's breast to hang pendant in the imaging volume at the rotation axis. The tube/detector assembly rotates around the rotation axis and acquires multiple 2D projection images of the uncompressed breast located at the rotation axis in 10 seconds. Slip ring technology allows continuous rotation of the x-ray tube/detector assembly concentric to the opening in the table to achieve multiple circle scans. Also, it has a controlled vertical motion during the rotation to perform a spiral scan over 20 cm of travel. The continuous 360° rotation is designed to have speeds up to 1 rev/sec. This system was validated through a series of breast-imaging phantom studies and and patient studies. The results show that the image quality of the CBBCT scanner is excellent and all phantom masses (tissue-equivalent carcinomas) and calcifications as well as human subjects' masses, calcifications and abnormalities can be detected faithfully using the CBBCT technique with a glandular dose level less than or equal to that of a single two-view mammography exam. The results indicate that the CBBCT imaging system has much better detectability of small breast tumors compared to the conventional mammography system.

A novel cone beam breast CT scanner: system evaluation

Conventional film-screen mammography is the most effective tool for the early detection of breast cancer currently available. However, conventional mammography has relatively low sensitivity to detect small breast cancers (under several millimeters) owing to an overlap in the appearances of benign and malignant lesions, and surrounding structure. The limitations accompanying conventional mammography is to be addressed by incorporating a cone beam CT imaging technique with a recently developed flat panel detector. Computer simulation and preliminary studies have been performed to prove the feasibility of developing a flat panel detector-based cone beam CT breast imaging (FPD-CBCTBI) technique. A preliminary system characterization study of flat panel detector-based cone beam CT for breast imaging was performed to confirm the findings in the computer simulation and previous phantom studies using the current prototype cone beam CT scanner. The results indicate that the CBCTBI technique effectively removes structure overlap and significantly improves the detectability of small breast tumors. More importantly, the results also demonstrate CBCTBI offers good image quality with the radiation dose level less than or equal to that of conventional mammography. The results from this study suggest that FPD-CBCTBI is a potentially powerful breast-imaging tool.

Preliminary System Characterization of Flat Panel Detector-based Cone Beam CT for Breast Imaging

Conventional film-screen mammography is the most effective tool for the early detection of breast cancer currently available. However, conventional mammography has relatively low sensitivity to detect small breast cancers (under several millimeters) owing to an overlap in the appearances of benign and malignant lesions, and surrounding structure. The limitations accompanying conventional mammography is to be addressed by incorporating a cone beam volume CT imaging technique with a recently developed flat panel detector. Computer simulation and preliminary studies have been performed to prove the feasibility of developing a flat panel detector-based cone beam volume CT breast imaging (FPD-CBVCTBI) technique. In this study, a specimen experiment is performed to confirm the findings in the computer simulation and previous phantom studies using the current prototype cone beam volume CT scanner. The results indicate that the CBVCTBI technique effectively removes structure overlap and significantly improves the detectability of small breast tumors. More importantly, the results also demonstrate CBVCTBI offers good correlation with pathology images with the radiation dose level less than or equal to that of conventional mammography. The results from this study suggest that FPD-CBVCTBI is a potentially powerful breast-imaging tool.

Real-time flat-panel detector-based cone beam volume CT breast imaging: phantom and specimen study

The clinical goal of breast imaging is to detect tumor masses when they are as small as possible, preferably less 
than 10 mm in diameter. Conventional screen-film mammography is the most effective tool for the early detection of 
breast cancer currently available. However, conventional mammography has relatively low sensitivity for the detection 
of small breast cancers (under several millimeters). Specificity and the positive predictive value of mammography 
remain limited owing to an overlap in the appearance of benign and malignant lesions, and surrounding structure. We 
propose to address the limitations accompanying conventional mammography by incorporating a cone beam CT 
reconstruction technique with a recently developed flat panel detector (FPD). We have performed a computer 
simulation study and preliminary phantom studies to prove the feasibility of developing an FPD-based cone beam CT 
breast imaging technique for a small size normal breast phantom. In this study, we report the design and construction 
of a novel FPD-based cone beam breast CT scanner prototype. In addition, we present the results of phantom studies 
performed on our current FPD-based cone beam CT scanner prototype, which uses the same flat panel detector 
proposed for the cone beam breast CT scanner prototype, to predict the image performance of the novel cone beam 
breast CT scanner, while we are completing the construction of the system.

Xianghua Lu

Papers

Evaluation of flat panel detector cone beam CT breast imaging with different sizes of breast phantoms

A novel cone beam breast CT scanner: system evaluation

Preliminary System Characterization of Flat Panel Detector-based Cone Beam CT for Breast Imaging

Real-time flat-panel detector-based cone beam volume CT breast imaging: phantom and specimen study

A novel cone beam breast CT scanner : Preliminary system evaluation