By Terri-Ann Gizienski

Breast tomosynthesis made headlines in 2011 when the technology first became available, commended for allowing radiologists to more clearly visualize invasive cancers that breast tissue had previously obscured with traditional 2-D imaging, and to differentiate them from benign cysts and lymph nodes that in the past would require additional imaging.

BT is quickly becoming the standard of care and is on its way to becoming the new “gold standard” for breast cancer screening as more women learn about its benefits and more facilities acquire the technology.



As the field migrates away from 2-D imaging and toward industrywide adoption of the newer technology, the growth of BT has presented the imaging field with a conundrum. Now that we can find more hard-to-see cancerous lesions and subtle calcifications under 3-D imaging, I and many of my peers are quickly discovering that traditional 2-D imaging is no longer sufficient for re-identifying and targeting those suspicious areas first found with breast tomosynthesis.

As a result, we’re beginning to see tomosynthesis integrated into other areas of breast health, allowing doctors and patients to experience the full spectrum of its benefits. Most recently, with the introduction of BT into image-guided breast biopsies and surgical staging, physicians have been able to use the advanced imaging to quickly pinpoint suspicious lesions or calcifications found during screening.

Beyond imaging: Breast tomosynthesis in biopsies
While the introduction of breast tomosynthesis has been a significant advancement for breast cancer screening, it presented a problem we didn’t know we had. We were detecting more hard-to-find lesions and faint calcifications, yet they could only be seen with 3-D imaging, which created a challenge when it came time to perform a 2-D imaging-guided breast biopsy. It was a frustrating realization of the limits of traditional breast biopsy that unfortunately resulted in a much longer biopsy procedure than necessary, and often translated into more time under compression for the patient, uncertainty for the clinician and inefficiencies for the facility.

Since that time, breast tomosynthesis has made its way into breast biopsy. First, with the integration into upright biopsy and, most recently, prone. While 3-D imaging-guided biopsy in the upright position provided new capabilities to breast biopsy, in most cases, I still opted to biopsy in the prone position, as I prefer the positioning and find patients have a better overall experience without having direct view of the needle. Though, in the cases when upright biopsy is necessary, the added capability of 3-D imaging is beneficial, as we provide breast tomosynthesis screening to the majority of our patients. Given all of this, my facility quickly adopted prone 3-D imaging-guided breast biopsy when it became available because we recognized the shortcomings of the current prone breast biopsy procedure, and we’ve immediately seen a difference since adoption. I am now able to more quickly identify challenging lesions and better target them using the same modality that initially detected the area of concern. The result: my patients can potentially spend less time under compression, reducing overall procedure time and improving their satisfaction. In some more extreme cases, I’ve even been able to biopsy patients who in the past may have required open surgical biopsy, clearly saving the health care system costs, but more importantly, alleviating the patient from the anxiety that comes with any surgical procedure and especially one that could result in a potential breast cancer diagnosis.

A far less discussed benefit of 3-D imaging-guided breast biopsies, but an equally important topic, is the reduction in radiation dose that it offers. Previously, positioning and targeting required separate exposures with 2-D image-guided biopsies. Now, with 3-D imaging-guided biopsies, these steps are combined, reducing patient radiation exposure, an ever-present consideration for many of us in this field and also a concern among some patients.

Breast tomosynthesis in treatment
Another area where I have found breast tomosynthesis technology has begun to lend its superior imaging capability is surgery, specifically preoperative surgical staging. Breast tomosynthesis technology now allows doctors to more clearly view lesion margins during surgical staging, resulting in more accurate surgical excisions with less positive margins remaining and a subsequently lower rate of re-excision. Studies have found that breast tomosynthesis can reduce re-excision rates in breast surgeries by 50 percent — an impressive finding, in my eyes, that supports this application of the technology beyond screening.



Surgical staging allows my colleagues to plan their surgery in advance of the procedure to ensure the best results possible. Proper staging can reduce the chance for positive margins following an extraction, which can result in a local recurrence of the breast cancer, which will then require re-excision. By offering better views of lesion margins than with traditional 2-D mammography alone, surgical staging with BT reduces this re-excision rate, which, in turn, reduces costs to the health care system. Additionally, reduced re-excisions can have a tremendous impact on patients as well, as it prevents them from experiencing the emotional toll that undoubtedly coincides with learning they need to return for a second surgery to once again attempt to remove their cancer.

The future of breast tomosynthesis
As tomosynthesis continues to establish itself as the standard of care in breast imaging and as radiologists begin to recognize it as the “gold standard” for detecting breast cancer, I expect that we will begin to see the technology further integrated across other areas of breast health. From diagnosis to treatment, we have come a long way and seen that the benefits of BT are infiltrating the continuum of care. With clearer visualization and the ability to better detect, biopsy and surgically remove cancerous lesions, breast tomosynthesis has proven its value for both physicians and patients.

To ensure we are utilizing the full potential of tomosynthesis, I believe we must push for wider adoption of the technology and expand research establishing its efficacy and value. As with all technological advancements, there are many barriers to widespread adoption: limited insurance coverage, costs for facilities to acquire the technology, etc. However, I am confident that our combined voices can propel this advancement, as the benefits will far outweigh the aforementioned challenges. As more women learn about, and subsequently demand, tomosynthesis, and as we continue to find new applications for its use, I encourage you to take this knowledge to the decision-makers at your own facility to ensure that you’re taking advantage of all breast tomosynthesis has to offer for both your facility and your patients.

About the author: Dr. Terri-Ann Gizienski received her master’s degree in public health from the University of Pittsburgh. She went on to earn her medical doctorate at Penn State College of Medicine, completing her radiology residency and breast fellowship at the University of Virginia. Dr. Gizienski works for Magee Women’s Hospital of Pittsburgh.