Journal of Breast Imaging, 2019, 1–8

doi:10.1093/jbi/wbz009
Educational Review
Received: February 21, 2019; Editorial Acceptance: March 11, 2019
Published Online: May 18, 2019

Educational Review

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Lesion Localization Using Digital Breast
Tomosynthesis: Where Did I Go Wrong?
Dipti Gupta, MD*, Sarah M. Friedewald, MD
Northwestern University Feinberg School of Medicine, Prentice Hospital, Department of Radiology, Chicago, IL (D.G.,
S.M.F.)

*Address correspondence to D.G. (e-mail: [Link]@[Link])

Abstract
The scroll bar on digital breast tomosynthesis has become an imperative tool that breast imaging
radiologists rely on for help in identify lesions on the orthogonal view, targeting breast ultrasound,
and performing challenging biopsies for one-view findings. The ability to predict the lesion loca-
tion using the scroll bar not only saves time in the diagnostic setting but also reduces screening
recalls when a finding can be confirmed as dermal. It is important, however, to recognize settings
in which the location prediction can be misleading, such as for lesions in thin breast tissue or the
anterior portion of the breast or if the breast is not appropriately positioned. In these situations,
radiologists can use other diagnostic tools for problem solving.

Key words: digital breast tomosynthesis; lesion localization; scroll bar.

ACCME Accreditation Statement:

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council
for Continuing Medical Education through the joint providership of the American College of Radiology and Society of Breast Imaging. The
American College of Radiology is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement:

The American College of Radiology designates this activity for a maximum of 1 AMA PRA Category 1 Credit(s)™. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. Credits awarded for this enduring activity are designated “SA-CME”
by the American Board of Radiology (ABR) and qualify toward fulfilling requirements for Maintenance of Certification (MOC) Part II: Lifelong
Learning and Self-assessment.

Technologists:
The American College of Radiology is approved by the American Registry of Radiologic Technologists (ARRT) as a Recognized Continuing
Education Evaluation Mechanism (RCEEM) to sponsor and/or review Continuing Medical Educational programs for Radiologic Technologists
and Radiation Therapists. The American College of Radiology designates this educational activity as meeting the criteria for 1 Category A credit
hours of the ARRT.

© Society of Breast Imaging 2019. All rights reserved. For permissions, please e-mail: [Link]@[Link] 1
2 Journal of Breast Imaging, 2019, Vol. XX, Issue XX

Lesion localization on digital mammography

Key Messages Before DBT, the tool kit for mammographic evaluation of one-
• The scroll bar on digital breast tomosynthesis (DBT) can help view findings was limited. The lateral view is the first step in local-
identify lesions on the orthogonal view, direct targeted breast izing lesions only seen on the mediolateral oblique (MLO) views
ultrasound, and guide the approach for biopsy of one-view find- (Figure 1). For example, if an area of architectural distortion (AD)
ings. only seen on the MLO view rises to a higher position on the lateral
• There are specific scenarios when the predicted lesion loca-

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view, the finding will be located in the medial breast.
tion on the scroll bar can be misleading, such as for lesions in Craniocaudal (CC) rolled views can be performed for lesions only
thin breast tissue and the anterior portion of the breast, or if the seen on the CC view, where the superior breast tissue is rolled slightly
breast is not appropriately positioned. (Figure 2). Rolling of the tissues changes the relationship of the superior
• In some cases, the location of the lesion relative to the nipple and inferior breast tissue with respect to each other. When obtaining a
on the scroll bar can help predict its true position. CC rolled view, the superior portion of the breast can be rolled medially
(CCRM) or laterally (CCRL). If the abnormality moves in the direction
of the roll, that is, the lesion moves more laterally on the CCRL and
Introduction more medially on the CCRM, it will be in the superior breast.
The effectiveness of digital breast tomosynthesis (DBT) in the Finally, step oblique views involve changing the obliquity of the
screening setting has been validated in several studies that show both X-ray beam in 10–15 degree increments starting from the view that
increased cancer detection rates and decreased recall rates with DBT the abnormality is seen. The goal of step oblique views is to obtain a
compared with digital mammography alone (1, 2). Tomosynthesis view only slightly different from the one where the asymmetry was
has also become an important tool in the diagnostic setting to seen. As the obliquity of the X-ray beam changes, a real finding will
evaluate and guide biopsy of asymmetries and one-view architec- persist, whereas an asymmetry caused by summation will resolve
tural distortions (3–5). (11). The lateral view, rolled views, and step oblique views all serve
The Breast Imaging Reporting and Data System (BI-RADS) to discern a persistent finding from a summation shadow by varying
lexicon published by the American College of Radiology de- the angle of the beam or the position of the breast tissue.
scribes an asymmetry as a finding only seen on one of the two
standard views of the breast (6). According to the lexicon, an
apparent mass only seen on one view should still be characterized DBT technology
as an asymmetry. In a retrospective review of one-view findings DBT is a mammographic technique whereby multiple low-dose pro-
on screening mammograms, Sickles found that 82.7% of the re- jection images are acquired in an arc across the breast and are re-
calls were due to a summation artifact, and cancers were only constructed into thin “slices.” (12–15) One millimeter single section
found in 1.8% (7). Interestingly, however, in reviews of missed reconstruction images can be reviewed on a workstation, allowing
cancers, 9%–38% of missed cancers were retrospectively vis- a 3D estimation of the location of the lesion relative to the breast
ible as a one-view finding (8–10). Characterization and local- tissue, thereby reducing the effects of tissue superimposition (16).
ization of one-view findings has improved significantly with the The total number of reconstruction slices depends on the thickness of
use of DBT, along with the ability to sample these findings using the breast. For example, if the compressed breast thickness is 5 cm, and
tomosynthesis-guided biopsy. slices are at 1mm intervals, there will be approximately 50 total slices. It

A B C

CC MLO ML

Figure 1. Lesion triangulation. If a finding is identified on the craniocaudal (CC) and mediolateral oblique (MLO) views, the location on the lateral view can be
predicted by drawing a straight line connecting the lesion between the standard CC (A), MLO (B), and mediolateral (ML) (C) views.
Journal of Breast Imaging, 2019, Vol. XX, Issue XX 3

A B
A B

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F
1

39
CC CCRM
H54 CC MLO

C C

Figure 3. An area of architectural distortion (circle) is best seen on the right

CC view (A), central to the nipple, localizing to the upper breast on the scroll
bar. The distortion (circle) is not readily apparent on the MLO view (B) until
the upper breast is more thoroughly investigated. Targeted ultrasound (C)
Figure 2. Rolled views for localization. A developing asymmetry (arrow) on
of the upper central right breast demonstrates an irregular mass (arrow)
the CC view (A) moves more laterally (arrow) on the CC–rolled medial (CCRM)
at 12:00, which yielded invasive carcinoma with mixed ductal and lobular
view (B), which localizes it to the inferior breast. A targeted breast ultrasound
features on biopsy.
(C) of the left lower inner quadrant shows an irregular, hypoechoic mass at
7:00 (arrow).
correlate is not identified on the orthogonal view, the location on the
is important to note that 5 additional reconstructed slices are added on scroll bar can help target breast ultrasound, which can be especially
to the nondetector (ie, the compression paddle) side of the image, as the useful in patients with large or complicated breasts. Instead of scan-
edge of the breast can be difficult to define because of its curvature, and ning half of the breast, a quadrant of the breast can be honed in on,
it is difficult to measure compression accurately down to the millimeter which can save time and prevent incidental findings.
(17). Therefore, for our example, there will 55 total slices, including the If a suspicious finding is identified on one view and no correlate
extra 5 slices on the CC view added to the superior portion. is identified on ultrasound, targeting the lesion for a stereotactic core
Each slice is assigned a slice number and is accompanied by a biopsy can often be challenging. This is especially the case for archi-
scroll bar that marks the position of that slice relative to the entire tectural distortion, which is often more conspicuous on the CC view
stack. In our example, a lesion on slice 25 of the CC view is likely in than on the MLO or lateral views. The scroll bar can be used to
the central portion of the breast on the lateral view. This informa- guide the approach for the biopsy in this situation. For example, for
tion from the scroll bar helps localize the position of the lesion on an area of architectural distortion only seen on the CC view that lo-
the orthogonal view. calizes to the superior breast on the scroll bar, a superior approach
should be selected. Using tomosynthesis for biopsy guidance can im-
prove the confidence for targeting one-view architectural distortion
Problem solving using the scroll bar (Figure 4).
The ability to localize one-view findings using the scroll bar can The scroll bar can also be used to confirm dermal calcifica-
help target breast ultrasound, guide the approach for stereotactic tions and reduce recall rates. While skin calcifications often have
or tomosynthesis-guided biopsy, and confirm the dermal location of classic lucent centers, sometimes calcifications may not be identifi-
superficial findings. able as dermal, based on morphology. Assuming the skin thickness
When an indeterminate finding is only seen on one view, the is 3 mm, the skin is imaged on the first and last 3 slices on DBT,
scroll bar can help localize where to search for the lesion on the where it is either touching the compression paddle or the detector.
orthogonal view. With this guidance and a focused search, a subtle Calcifications and masses on those slices can therefore be con-
correlate is often identified on the orthogonal view, where the finding firmed as dermal (Figure 5). However, calcifications can still be
may originally have been felt to be occult (Figure 3). Even when a dermal and not be within the first or last 3 slices, localized in the
4 Journal of Breast Imaging, 2019, Vol. XX, Issue XX

A B C

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F
1

24

45 CC ML CC
H

Figure 4. Using the scroll bar to determine the biopsy approach. Architectural distortion (circle) in the outer anterior left breast is only identified on the CC view
(A). A superior approach was selected for the tomosynthesis-guided biopsy because the scroll bar localized the distortion to the upper breast. Postprocedure
mammogram (B, C) demonstrates the biopsy clip (arrow) in an appropriate position in the upper outer breast. Pathology yielded invasive ductal carcinoma,
grade 2.

calcifications against the detector or a skin tangential study can

A B be performed.

Pitfalls with DBT scroll bar localization

While the scroll bar usually accurately localizes lesions on the or-
thogonal view, there are a few specific situations where the scroll
bar can lead the reader astray. Recognizing the factors that lead to
the seemingly inaccurate lesion localization can help prevent inter-
pretation errors.
L
-1
Location Based on the True Lateral View
It is important to remember that the scroll bar predicts the lesion
location on the orthogonal view. At the time of screening mammog-
raphy, nonorthogonal CC and MLO views are performed, and the
principles of triangulation have to be taken in to account. When
57 viewing the scroll bar on the CC view, the location of the lesion is
M
predicted on the true lateral view, not the MLO view (Figure 6). As
Figure 5. Using the scroll bar to confirm dermal location. An asymmetry discussed earlier, medial lesions rise higher on a true lateral view com-
in the right inferior breast (circle) is seen on the first slice of the MLO pared with the MLO view. Therefore, when a lesion is medial on the
tomosynthesis view (A). The technologist realized the mole marker had fallen CC view, the scroll bar will predict the lesion location to be higher
off at the time of the screening exam. The MLO view (B) was repeated with than what is seen on the MLO view. Conversely, a lateral lesion will
a round mole marker in place, and it confirms the asymmetry to be dermal.
be located lower on the scroll bar than expected based on the MLO
view because the scroll bar reflects that the lesion will be lower in lo-
areas where the skin in not touching the equipment. For example, cation on a true lateral view compared with the MLO view.
because of the curvature of the breast, the skin near the nipple
is located deeper in the stack compared with the posterior por- Nipple Positioning
tion of the breast, where the breast is thicker. Last, as the extra 5 When the breast is appropriately positioned, the nipple should be in
slices are added to the compression paddle side of the breast, if the the center of the breast and the center of the scroll bar, demarcating
measured compression thickness is perfectly accurate, dermal cal- the superior and inferior breast on the lateral view and medial and
cifications may appear deeper in the stack on the nondetector side lateral portions on the CC view. However, in some patients, the
(18). If calcifications are suspected to be dermal but not within the nipple may not be in the center of the breast or more commonly, it
first or last 3 slices, either a reverse view can be obtained with the may be malpositioned in one extreme direction.
Journal of Breast Imaging, 2019, Vol. XX, Issue XX 5

A B C

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F
1
11

CC
MLO 57
H ML

Figure 6. Triangulation using tomosynthesis. An irregular mass (circle) is seen central to the nipple on the MLO view (A) in the left breast, but it localizes to the
inferior portion on the CC view scroll bar (B). As lesions in the outer breast fall on the lateral view, the ML view (C) confirms the mass to be in the lower breast
(circle). On ultrasound (D), an irregular mass (arrow) is seen at the left 5:00 position, corresponding to the finding on mammography.

A B C

L L
1 1

20
29

73 MLO CC 73 MLO
M M

Figure 7. The scroll bar is misleading when the nipple is malpositioned. The tomosynthesis right MLO slice (A) shows that the nipple is not optimally positioned
and the breast is drooping. The mass (circle) is localized on the MLO scroll bar to the lateral breast, although the true position is in the medial breast (circle) on
the CC view (B). The nipple (arrow) is in focus toward the lateral breast and not in the middle of the scroll bar (C). The relative location of the mass on the scroll
bar is closer to medial compared with the position of the nipple.

In these cases, the reader should note the scroll bar location to localize closer to the detector side (Figure 8). For example, in a
when the nipple is in focus and use that as a reference for local- patient with a compression thickness of 20 mm, the 5 extra slices
izing the lesion (Figure 7). For example, in a patient with reduction account for a significant portion of the image stack, and there are
mammoplasty where the nipple is elevated (in focus toward the head 20% more images toward the compression paddle side of the breast.
on the scroll bar), a lesion toward the middle of the scroll bar on the In these cases, a lesion in the center of the breast will appear to be
CC view would actually be in the inferior breast. closer to the detector side on the scroll bar.
Because of the curvature of the breast, the anterior portion of
Lesions Localizing to the Detector Side the breast is usually thinner and more compressible than the pos-
Lesions may erroneously project closer to the detector on the scroll terior portion is. The scroll bar, however, reflects the thickness of
bar in patients with thin breast tissue and when the finding is located the entire breast, and thus the anterior portion may be included
in the anterior portion of the breast. in only a small portion of the scroll bar. Anterior lesions may pro-
To account for inaccuracies in measurement of the compression ject toward the detector side of the scroll bar, as the compression
thickness, 5 additional slices are added to the stack toward the com- paddle flexes toward the detector in the anterior portion, where the
pression paddle side of the breast to ensure that a portion of the breast is thinner. In such cases, it is helpful to assess the location of
breast is not excluded on the reconstructed images. While the extra the lesion in relation to the nipple, instead of solely relying on the
5 slices do not make a significant difference in the majority of cases, location determined by the scroll bar (Figure 9). The principle of
in patients with very thin breasts, the extra slices can cause a lesion localization on the scroll bar assumes even compression throughout
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A B

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F
1
–5

24
H
117.8773 Newton
CC
Zoom: Scrn B Rm 2228, RL
18 mm, 0.015 dGy, 26 kV 61.2 mAs
MLO
Slice: 1 mm

Figure 8. Localization inaccuracy in thin breasts. A group of coarse heterogeneous calcifications (circle) in the central breast on the MLO view (A) localizes to the
inferior breast on the CC view scroll bar (B). Additional image information reveals that the compressed breast thickness is 18 mm (arrow). The extra 5 slices on
the compression paddle side in this thin breast localize the lesion closer to the detector side.

A B C D

F F
1 1

12

23

CC MLO H
62 62
H

Figure 9. Localization of anterior breast lesions. Routine right CC and MLO views (A, B) demonstrate a focal asymmetry (circle) in the right upper outer quadrant
anterior depth. The scroll bar on the tomosynthesis CC view (C) localizes the mass (circle) toward the feet (detector side of the scroll bar.) The nipple (arrow) is
also best in focus toward the feet (D), instead of the middle of the scroll bar, and it localizes lower on the scroll bar relative to the asymmetry. Therefore, the
asymmetry is correctly localized relative to the nipple.

the breast. There may also be differences in compressibility of the Superficial lesions
breast based on tissue composition that may lead to uneven com-
In the vast majority of the cases, the first 3 slices in the scroll bar are
pression and errors in localization. In such cases, the position of the
imaging of skin. Findings in these slices can be considered dermal
lesion on the scroll bar relative to the nipple may again be used to
and, therefore, do not need additional diagnostic evaluation. Rarely,
aid in localization.
in patients with very thin breast tissue and thin skin, it is possible
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A B

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C D

F
L
3
3

34 MLO CC 39
M H

Figure 10. Localization of a superficial lesion. A group of calcifications (circles) in the right lower outer quadrant is in focus on slice 3 of the CC and MLO views
(A, B). The tangential view (C) shows that the calcifications (circle) are superficial but not dermal. The specimen radiograph (D) from the stereotactic core needle
biopsy confirms the targeted calcifications (circle) and yielded ductal carcinoma in situ. It is likely in the unusual case that the skin thickness was less than 3 mm,
and, therefore, the calcification location may mislead the radiologist, suggesting that the calcifications were dermal.

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