For cone compression, should I order diagnostic mammography with tomosynthesis?

Digital Breast Tomosynthesis Can Replace Cone Compression Views in Diagnostic Mammography

For diagnostic workup of mammographic findings, you should order diagnostic mammography with tomosynthesis instead of traditional cone compression views, as DBT has been shown to provide equivalent or superior diagnostic accuracy while potentially reducing radiation exposure. 1, 2, 3

Evidence Supporting DBT Over Cone Compression

Diagnostic Performance

• DBT demonstrates significantly superior diagnostic accuracy compared to conventional mammography with cone compression magnification views, with an area under the curve (AUC) of 0.93 versus 0.87 (p=0.0014) in the assessment of mammographic abnormalities 4
• Multiple ACR Appropriateness Criteria guidelines confirm that DBT can be used with or without spot compression views in the diagnostic context, and one-view breast tomosynthesis has been demonstrated to be equivalent to or better than supplemental diagnostic mammographic views 1
• In a retrospective review of 341 lesions assessed by both modalities, spot compression provided more diagnostic information than tomosynthesis in only one case (due to technical positioning error), leading investigators to conclude that spot compression mammography is now obsolete where tomosynthesis is available 5

Clinical Applications

• DBT is particularly effective for evaluating:
  • Masses and asymmetric densities 1, 6
  • Architectural distortions 5
  • Noncalcified lesions 1
  • Screen-detected abnormalities requiring workup 1, 2

Radiation Considerations

• DBT spot compression views deliver comparable radiation doses to standard DBT views (1.97 mGy vs 1.78-1.81 mGy) 7
• When using synthesized 2D images (sDM) reconstructed from DBT datasets instead of acquiring both standard 2D and DBT images, radiation exposure is reduced while maintaining diagnostic performance 1

Practical Implementation

When DBT Replaces Cone Compression

• For masses, asymmetries, and architectural distortions: DBT alone is sufficient without additional cone compression views 5, 6
• For suspicious findings identified on screening: Proceed directly to diagnostic mammography with DBT 1
• For palpable abnormalities in women ≥40 years: Diagnostic mammography with DBT is the initial imaging examination 1

When Cone Compression May Still Be Useful

• Magnification views remain helpful specifically for evaluating associated microcalcifications, as DBT's primary advantage is in noncalcified lesions 1, 2
• Technical failures where the area of concern is inadequately positioned during DBT acquisition 5

Optional DBT Spot Compression Enhancement

• If your equipment allows DBT spot compression (newer capability), this can further improve diagnostic performance with increased accuracy (72-75% to 90-94%), improved specificity (68-75% to 90-94%), and better inter-reader agreement (kappa 0.21 to 0.45) 7
• However, standard DBT views without spot compression are generally sufficient for most diagnostic scenarios 5, 4

Recommended Ordering Approach

Order: "Diagnostic mammography with digital breast tomosynthesis" rather than "diagnostic mammography with cone compression views" 1, 3

• This provides the radiologist flexibility to add magnification views only if microcalcifications need characterization 1, 2
• The Italian College of Breast Radiologists and ACR both support DBT replacing traditional spot compression in most diagnostic situations 1, 2
• Multiple guideline organizations (ACR, NCCN, Italian College of Breast Radiologists) now recommend DBT as standard for diagnostic workup 1, 2, 3