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    Contents lists available at ScienceDirect
    The Breast
    Original article
    Agreement between digital breast tomosynthesis and pathologic tumour size for staging breast cancer, and comparison with standard mammography
    M. Luke Marinovich a, *, Daniela Bernardi b, Petra Macaskill a, Anna Ventriglia b, Vincenzo Sabatino b, Nehmat Houssami a
    a Sydney School of Public Health, Sydney Medical School, Edward Ford Building (A27), The University of Sydney, NSW 2006, Australia
    b U.O. Senologia Clinica e Screening Mammografico, Dipartimento di Radiodiagnostica, APSS Trento, Italy
    Article history:
    Received in revised form
    Available online 10 November 2018
    Breast cancer
    Tumour size
    Purpose: Tomosynthesis is proposed to improve breast cancer assessment and staging. We compared tomosynthesis and mammography in estimating the size of newly-diagnosed breast cancers.
    Methods: All pathologically-confirmed cancers detected in the STORM-2 trial (90 cancers, 85 women) were retrospectively measured on tomosynthesis by two independent readers. One reader also measured cancers on mammography. Relative mean differences (MDs) and 95% limits of agreement (LOA) with pathology were estimated for tomosynthesis and mammography within a single reader (Analysis 1) and between two readers (Analysis 2).
    Results: Where cancers were detected and hence measured by both tests, tomosynthesis overestimated
    pathologic size relative to mammography (Analysis 1: MD 5% versus 1%, Analysis 2: 7% versus 3%; P ¼ 0.10 both analyses). There was similar, large measurement variability for both tests (LOA range: 60% to þ166%). Overestimation by tomosynthesis was attributable to the subgroup with dense breasts (MDs ¼ 12e13% versus 4% for mammography). There was low average bias for both tests in the low-density subgroup (MDs ¼ 0e4%). LOA were larger in dense breasts for both tomosynthesis and mammography (P 0.02 all comparisons). Cancers detected only by tomosynthesis were more frequently in dense breasts (60e68%): for those tumours size was estimated with increased measure-ment variability (LOA ranging from 75% to þ293%).
    Conclusions: On average, tomosynthesis overestimates pathologic tumour size in women with dense breasts; that difference is more likely to impact management in women with larger tumours. The main advantage of tomosynthesis appears to be detecting mammographically-occult cancers; however tomosynthesis less accurately measured those cancers in dense breasts (large measurement variability).
    1. Introduction
    Digital breast tomosynthesis is a recent evolution of full-field digital two-dimensional (2D) mammography involving three-dimensional (3D) transformation of breast images. By acquiring images in a series of thin slices through the breast, tomosynthesis (3D-mammography) has the potential to improve visualisation of breast cancer (BC) due to a reduction in the effect of tissue super-imposition on standard 2D-mammography [1]. Current