Tomo Case Review

Digital Breast Tomosynthesis Workshop

Welcome to the digital breast tomosynthesis workshop.

We're gonna start with a whole bunch of cases
and we're gonna view them as if we were really sitting in
front of a workstation.

Our goal really is to mimic a day in the reading room.
We're gonna show a variety of cases.
A lot of them have the DBT movies.
You need to really play, pay close attention
as the movies go along.
Sometimes you see a finding just on a few slices.
If you blink or don't pay attention, a finding
that significant may go back and forth.

First Case: Ideal Case for Digital Breast Tomosynthesis

The first case I'm gonna show you is an ideal case
for digital breast tomosynthesis.
It's a 61-year-old who presented for screening.
She had no risk factors.

Here are her craniocaudal views.
These are the standard two field,
full field digital images that as you know, are required
until recently to be obtained in addition
to the tomosynthesis.

See if you see any abnormality,
I'll give you a heads up that she does have cancer.
There is a cancer on these images.
That's the craniocaudal, that's the MLO.

If you were reading this, pass it recall.
Don't see it. Majority is voting for passing it.

Let's add the tomosynthesis.
Here's the right,
Let's go back
And this is how we actually view them.
We usually watch the movie go back and forth
and then we may scroll slower ourselves.
But these, I'm just gonna let go
back and forth a couple times.
You'll see each one twice
and you'll see we talked a lot about how long it takes
to interpret the tomosynthesis.

This is about the regular speed
that we're seeing these go through.
I'm gonna play that one again
because that's the one that has the cancer on it.
If you didn't see it, look at the top part of the screen.

Here's the left MLO.
Again, this is the breast with the cancer in it.
Here's the right MLO.
This is a normal.
This is the normal side.
If you notice a little number at the bottom,
that's the number of slices there are.
You know those are 61 slices that you've been through.

Now I've given you the answer obviously.
Obviously your assessment should have changed from
the full field digital
to the digital tomosynthesis.
And by doing ultrasound you can easily see
that there is a left breast cancer at the
two o'clock position.
Here it's with elastography showing
that it is a hard cancer.

Here full field digital a blow up.
You can see some architectural distortion, a hint
of a mass, but it's much easier on the tomosynthesis
to see the spiculated mass.
And nobody would've any question
if you could see this on here.
And it is obviously much easier on a regular monitor than on
the screen to be able to see the spiculated mass,
the irregular shape, the irregular margins.
No question that this would be a cancer.

Second Case: More Difficult Cancer Detection

Here's a case that's even a little bit more difficult.
Here are MLO views again,
there is a cancer here and I'll give you a clue.
It is a left breast.

The craniocaudal views,
this is the normal
and this is the side with the cancer.
As this goes by, is there anybody
that sees the cancer?
Yes, I see a few yeses.
Anybody want me to play it again? Yep.

It does the training
and the learning curve for this does take a while.
You really do need to see a lot
and look at a lot yourself.
And it does help when you have control of the mouse.
You can go back and forth over an area that you may
be concerned about.

'Cause this is the normal side
and the abnormal side.
Look as you're looking, look up in this area.
Did everybody see the cancer? Yes.
No, I see a lot of yeses.

Easier to see on the tomo,
and this is probably not would've been seen
without the tomosynthesis,
but we also can use tomosynthesis as a problem solving tool.

Problem-Solving Case: 59-Year-Old Screening Recall

Here, this 59-year-old presented for screening
and based on this screening exam she was recalled.

Here's our 2D which prompted the recall.
Can everybody tell me
where they think she would've been recalled
for on these craniocaudal views?
Left or right? Central,
Right breast Central, right.
Maybe here. Any other choices?
How about here? Maybe
Any other guesses, educated comments, educated guesses.

Let's keep looking.
Here's our 2D screening MLO views.
She was recalled
and she had a lateral and a spot.

What do you think it was? Workup done, not done.
I see a lot of nos like we're not done.

Obviously this is a tomosynthesis workshop.
We could have done ultrasound,
we could have done more spots, but we went to tomosynthesis.
This was pretty soon after we had gotten the tomosynthesis
and I said let's do the tomosynthesis.

How many people see the cancer going by?
About two thirds.

Take a look in this area, for those of you
who didn't see it,
you're looking right here.
And if we look on the craniocaudal
look up here, it's gonna come back around
again.
Up here you're gonna see the spiculated mass.

That's what we're looking for. We're looking
for the spiculated masses.

Why didn't we see it on the spot here,
it's very clear on the tomosynthesis,
a spiculated irregular shaped mass.
Actually it was outside the paddle
where the technologist had done the CC spot.
This was lateral to where the paddle was.
You'd have to be looking really hard
to find it in here.
It's relatively underpenetrated
and outside the view of the paddle on the MLO,
on the tomosynthesis, easy to see, pretty hard to see.
And with the dense tissue here.

The advantages of DBT in this case,
if she had had the tomosynthesis as the first exam,
perhaps she would never have been recalled.
She would've been recalled as a BI-RADS four
or five gone directly to ultrasound
and ultrasound guided biopsy would've saved that extra step.
The lateral and the spot.

If that had been the only things that were done,
it's possible that somebody could have said okay this is a
BI-RADS three or perhaps even a BI-RADS two and made an error
and not pursued anything further.

The tomosynthesis clearly had an advantage
for this patient.

Synthesized Imaging Advantages

I'm just gonna digress a moment
and talk a little bit about the synthesized imaging that Dr.
DA has talked about a little bit before.
We've been using it now for several months
and there are several nice advantages
to the synthesized images.

One thing is they now have a D metal feature
and that really basically takes away that artifact,
that zipper artifact
that you typically would see from the
tissue markers from nipple markers.
If the technologist press this DME button,
it takes away that artifact.
Otherwise when you get your synthesized image,
it actually can obscure a whole length of
breast parenchyma.

That artifact is gone on the synthesized image.
This person has a tissue marker in place
and you notice it's very minimal
artifact surrounding that tissue marker.
Because of the dedal feature,
there are a little bit more contrasty on the synthesized
image than the full field digital image.

We're also noticing that you can see a lot of calcifications
on the synthesized image
that you might not see on the full field digital image.
You can't really appreciate them here.
But if we look at just a little magnified area,
if you look here on the synthesized image,
you actually see there's a cluster
or group of calcifications here
where on the full field you'd be very hard pressed
to have picked them out.

Then the question becomes are these real or are they noise?
We've worked up a number of these now with spots
and indeed the vast majority we actually see on the spots
and they are real calcification.

Here they are on the spot mag.
I realize it's difficult to see in the room
but they are actually real.
You can see them over here blown up
that they are real calcifications.

DBT can be really helpful
for calcifications when you use the synthesized images.
Also helpful for calcifications
when you're not sure if they're in the skin or not.

If you're deciding whether you need to recall a patient
for calcifications and you look and
behold you turn on the tomosynthesis
and there's a calcification just sitting in the pore
or sitting on the first few slices
or the last few slices of your tomosynthesis
and you know they're within the skin
and you don't need to pursue any workup further
because we've all been at the stereotactic table
with a patient and you go to do your stereotactic biopsy
and behold you do the depth and they're in the skin
and then you start doing a skin workup
after the patient has been all prepped
and already for the biopsy
and nobody's very happy under those circumstances.

Here's another example of skin calcifications.
You can see the calcifications in the skin here
and here you can see all the pores very nicely
on the tomosynthesis.
Again, right in here, you clearly know they're in the skin
and nothing further.

Conversely, if you think they might be in the skin,
tomosynthesis may show you they're not in the skin
but they're in the middle of the breast.

Here are calcifications.
We were thinking perhaps they're in the skin,
but here you can see that they are not.
And again, I realize it's hard for them to project.
But if you trust me there are some calcifications here.
You can see they're at the same plane as the nipple.
They're right in the middle of the breast.
They really are here. I can see them here
but I realize you can't see them over there.

Practice Case: Palpable Abnormality

Let's do another practice case.
This woman presented
with a palpable abnormality in the left breast.

Here's her craniocaudal views.
I think we organized this
where I do the left breast and you do the right breast.
Yeah, pretty much. Yeah we did that 14.

Here's her MLO views.
Here are her spots.
Some more spots.

What are you thinking at this point?
What is she showing me? Gimme an ultrasound help.

This is the tomosynthesis workshop. Here's the tomo
and play it again.
Alright There.
And here's the MLO.

As you're going through it at this
point, which did you prefer?
The DBT, the full field,
the spots neither do you really just want the ultrasound.

The ultrasound here was much easier
right here you have no problem.
You put the, it is much quicker and much easier.
You put the ultrasound probe down on the palpable
abnormality and ultrasound is a clear BI-RADS five,
there's no question it's at 12 o'clock,
five centimeters from the nipple.
Even hard in retrospect to find that on the tomosynthesis.

Natural History of DCIS Case

This is a 46-year-old who was diagnosed
with DCIS three years ago.
We talked about sometimes people not returning
for BI-RADS three but even with the diagnosis of DCIS,
she didn't return so she didn't have any treatment.

This is the natural history of DCIS.
This was at the time of diagnosis
and you can see all the calcifications here in the upper outer
quadrant on left breast.

Here it is three years later or two years later
and here's her tomosynthesis.

You can clearly see the calcifications.
They're a lot more extensive than they were.
We can see the segmental calcifications, they'll come in
and out here, we'll play
it again, which
there's no question that you can see the calcifications
and here they are on the MLO view.
You can see if as it comes back around, if you look
between here and here you'll see them.

And just to really show you one slice from the DBT,
you can see that they are here
and they are fairly extensive.

Limitations of Tomosynthesis: BRCA Screening Case

We've seen a kind of a variety of where
tomo has helped a little bit where it's not helped.
But let's look at this case
'cause we wanna be sure that tomosynthesis is the be all
and end all or be sure that it's not.

This is a woman who underwent BRCA screening.
She's 27 years old.

If you go back and forth on this tomo, if you see,
you wouldn't be able to see the cancer.
However, if you see the ultrasound, it's a clear
obvious BI-RADS five cancer again.
And you can see right where it was.
This is the images are reversed
but you can see that the cancer is up here.
Here's the tissue markers are here
and here's where the cancer, the cancer lies.

Tomosynthesis as Problem Solver: Tissue Markers Case

Let's see. Here's tomo sense
as a problem solver.

This patient is 47 years old.
She's had two stereotactic biopsies that showed DCIS.
One group of calcifications were only seen,
which she was positioned
for stereotactic bio at an outside facility.
She'd come for biopsy of one group
and they actually saw two groups
and they biopsied two groups.

Your surgeon comes in
and your surgeon tends to be a little bit aggressive.
She wants an answer and she wants it yesterday.
She wants to know if patient is a candidate for a lumpectomy
and how far apart are the tissue markers.

You look and you say, well you know what, I can't tell
'cause I could only see one tissue marker.
I can't see the two tissue markers
in two planes we did exaggerated images
and there's really no help.

How could we possibly use tomosynthesis to help us?
Here we did tomo.

Here you see we have the maximum bloom from both
of these tissue markers with the artifact on the same slice.
We know that with respect to their location,
they are in the same plane.
We can tell her exactly how far apart they are
'cause we can measure from front to back how apart they are.
And that's where they are. They're in the
exactly the same plane.

It really helped to be able to show those for her.
There you can see them coming in and out a plane.
We know craniocaudal,
they're in exactly the same location.

Studies on Cancer Detection with Tomosynthesis

I'm just gonna go over a few things about tomo
and at the end if there's any time
for questions, we welcome them.

I spoke to you earlier about Dr.
Scon and he's some very nice articles
and abstracts have come out in the last few
years from what he's done.
And in this specific one
that he published in radiology last year, he compared
how many cancers he found on screening with
2D mammography, digital mammography.

He found six cancers, six patients
with cancer per a thousand detected with mammography alone.
And that increased to eight
per a thousand when he added tomo.

Screening Case: 50-Year-Old with Dense Tissue

This is an example, this is a 50-year-old comes in
for a screening mammogram.
She has a typical heterogeneously dense tissue similar
to the discussion we're having earlier about breast density.
The whole breast is not necessarily dense
but you know there are several areas behind the nipple,
centrally and upper quadrants that are quite dense.
Do you see anything, anybody?

Here the MLO views
and here the CC views side by side
and left.

I have the both MLO tomo side by side.
I'm gonna show you the left, Which is
where we think something may be.
You tell me if you see anything.

I let it go through its cine loop all the way
through, sometimes twice, kind of getting a feeling
for what I'm looking at.
And then I like to be able to actually touch it
and go through and stop it one millimeter at a time
as I'm going through it
to see if I can figure out where something may be.
Tell me if you see anything.

I'm stopping it right there.
There is a small, not
that small actually a spiculated lesion right here
on the MLO view.
You can see lines coming out of it. Do you guys see that?
Yeah.

Very good for whoever sees that there's lines,
it's subtle, it's in the middle of that dense tissue.
You have to be paying attention
as you're going through this case.

You cine loop, you let it run through once or twice
and you go back and look at it.
Remember we don't have to, we don't have CAD as of yet.
You have CAD for the 2D only.
If you're used to looking with CAD,
you don't have that as of yet.

Here's the craniocaudal on the left,
I'm just concentrating on the area
that we're looking for here.
Do we see it? I'm gonna go backwards
And Go through again, scroll through
and I'm gonna stop it and go back.
Are you buying into it that it's right here?
Sort of you're more convinced on the MLO view.

But this is the area we're looking at.
Subtle but it's there
and I have just a blow up of that area
so I'm gonna show it to you in the CC projection again
seeing if you can see it better now.
Can you see it better? Yeah.

Certainly when you're looking in front of your monitors,
your eyes are a foot away from the monitors.
They're high resolution monitors,
much different than lights on which is what we have here.
This is an artificial situation.

With lights on everywhere, you're gonna be able
to see this lesion very nicely coming out
and it's right there and you're gonna be able
to get a very good look and go back
and forth whether you use your mouse
or whichever way, whatever buttonology you have,
have to see through.

Here is a blow up of the MLO, the left MLO
and I'm gonna play that again for you
so you can see it And it's right here.

I'm going through all this methodically
and painfully for you because
I wanna make sure you all can see it.
Is that true? Right here
we have lines coming out of this.
This is a lesion that's irregular right in this area
and it's gonna be that subtle.

That's what we were looking at.
And here is just a picture of that slice,
that one millimeter slice.
I took a picture in the CC
and here it is in the MLO tomo projection right there.

It's slice 43 on the MLO view and on the CC slice 36.
And that was where the cancer was in this patient.
That patient was then
after she had her exam, went on to ultrasound
and we saw this hypoechoic irregular mass
and this was an invasive ductal carcinoma.

And here I have the follow-up MRI
and there's a enhancing mass.

Another Screening Case: 58-Year-Old with Dense Breasts and Cysts

This is another patient, 58-year-old, she comes in
for screening and she also had a combination 2D
and tomo exam.
And she has dense breast tissue bilaterally.

Here's the right MLO, here's the left.
She also has a history of cysts.
Here's the right CC
and the left CC with some smooth outline masses.

Here are the MLO side by side on the 2D
and here on the CC views.
And I'm going to play for you first the left.

You can see how smooth the outline
masses that are benign.
You can see the border so nicely with the tomo.

I'm letting that play through and I'm going backwards
and I'm gonna stop it right there.
You see the, you can characterize the masses very nicely
with their cysts or fibroadenomas.
You see the borders very well.
This is in a patient with cysts.

Here is the right MLO view and I want you to focus up here
and tell me if you see anything.
I'm gonna give you the answers here.

We're looking at this area up here
and I hope they come through a little bit.
Let me move on. Here's a slice, a slab of that area
and this is what I was trying to show you.

If I go back again, I'm just gonna let it play
now you know where it is, it's up here.
Can you guys see it? It's tough to see only on one view
and sometimes the tomos don't play as well as we like.

Here's the CC, the right CC
and we're thinking we don't know
where it is on the CC view.
Is it central at 12 o'clock? Is it way lateral?
We can't really tell this patient has very dense tissue
and we really just can't see where exactly this is.

This is a patient that had a combination exam
and she was called back.
And what we've been doing while we're getting
our workflow and also our learning curve
with digital breast tomosynthesis,
we do our spot views since we saw something on the MLO view,
this is the way we're doing our spot view
and then we also added an exaggerated CC tomo
in the lateral aspect.

This is the spot view.
Do you think that answers our question?
Does that look better? Hard to tell.

Here's the exaggerated tomo view.
And this is a blow up of
that area concentrating in the outer part.
I'm gonna go backwards. I have the
CC, exaggerated CC tomo right there
but I have a blow up of it thinking that you'll be able
to see it better because I know that it's difficult
to project on the wall.

Do you see that area architecture distortion spiculation
It's way lateral.

There is a possibility
where you're doing your standard four views
that you're not going
to get all the breasts you're gonna miss way lateral,
the tail of the breasts.

You may have to bring the patient
back when you recall them.
Whether you do your spot views
or rolled views, you may need to add another view
to really evaluate the outer part of the breast.

And this was a lesion that was way lateral.
I initially seen only on the MLO view.

This is a tomo slice, an image of that area
with lines coming out of the spiculated mass.
And on ultrasound, this was pretty subtle
but you have a hypoechoic lesion here
in the upper quadrant And this was invasive ductal
carcinoma in DCIS.

Studies on Lesion Characterization

Many studies have come out in the last two years speaking
about borders lesion characterization.

Dr. Ian found a few years ago
and published it that in terms of visibility ratings
with tomo it's similar to doing the mammographic spot views.

I think if you do embark on tomo you'll figure that out
and you'll find your own way when you're comfortable letting
go of your spot views and just doing tomo instead.

As you learn it's good to do both
until you get more comfortable with what you're looking at.

Asymmetric Tissue Recall Case: 47-Year-Old

This is another patient, she's 47
and she was recalled by us
because we thought that her tissue looked a little
asymmetric here and also here it was a pretty soft recall.

And some of my partners recall things,
very low threshold to recall.

This was a patient with fatty tissue, not even very dense
but we thought we could see these two areas
that we had a question about.

We do what we usually do.
A lot of our patients are waiting for their results
so they're not actually gone out of the building.
We did a couple spots,
one on each side in the projection we're seeing at 2D
and then we added a CC tomo and a left MLO tomo.

We're using tomo now for our workups.

This was the CC spot and the left MLO spot
and we were not sure still
and here are the single view tomos we did as part
of the diagnostic workup
'cause this patient did not start out with tomo,
she just had the 2D.

I'm letting this play for you.
Remember this was a wispy density we thought we were seeing
and by scrolling back
and forth my partner felt comfortable that he answered
that this was overlap and this area was fine.
And then the same thing here.

If you're on the fence and you're not sure it's helpful
as a diagnostic workup to answer a question you may have.

This area again,
by doing the tomo we felt comfortable that we cleared it.

It's helpful even for women with fatty breasts
or scattered breast tissue
to answer a question also to identify cancer.

We're finding cancers in women in
with scattered breast tissue.

Screening Case: 64-Year-Old with Dense Tissue

64-year-old with a screening mammogram.
Do you guys see anything?
She has dense breast tissue.
I'm putting those arrows on there for you.

This is the area we're looking at both on the CC way
posteriorly and also on the MLO view.
It seems like I have a predilection
for picking cases on the right.

Here the MLO view side
by side 2D we're looking at this area
and here the CC views
and we're looking back here way in the posterior right CC.

The patient was recalled for a spot compression view
and we also started with a tomo, right?
MLO view. We don't wanna over radiate the patient,
we wanna see if we can get the answer
and add minimal radiation.

Here's the spot view. This is on the edge.
We definitely see something we don't like back
here in this lady.

Here's the tomo view, we're gonna let that play.
Remember we're looking up here.
Is that clear to all of you
that there's something going on up there?
What do you guys think? Yeah.

I'm going back and forth just to make sure.
Is there something up there?
It's not overlap,
it's not just an asymmetry I'm looking at it's a real
finding and I'm seeing
that there's truly something up there.

Here I also have a blown up
MLO 2D of this area
so you guys can see it a little better I think.
Yes. Does that help? Everything should be that big, right?
Then we wouldn't miss anything.

We're up here spiculated mass in a very dense
pattern right on the edge.
That's that sweet spot up there. We always gotta look up.
You gotta look way posteriorly like on the CC view
where this is located up.
Look at the edges of the breast.
Assume we can't just always be looking in here.
You have to look at all the edges.

And there is this cancer way back here
and this is a tomo slice of it.
Beautiful lines coming out of it.
And here it is an ultrasound, an irregular mass hypoechoic.
This was an invasive ductal carcinoma.

Screening Case: 41-Year-Old with Multiple Lesions

I'm gonna show you one more case. This is a 41-year-old.
She comes in for a screening
and I already kind of have the arrows there for you.

It's easy to see there's something there.
Do you all agree something is there? Yes.

And I'm gonna start with a CC.
There's something in that right there. We agree.

But what I'd like you to see, and I hope you can see it.
We have one lesion that's more posterior
and I'm scrolling now forward
and I want you to appreciate
that there's something else going on here.
There's lines coming out of another area, it's subtle,
there's a few calcifications which you cannot appreciate.
I know based on the projection there.

But we started thinking there may be something more than we
initially saw on the 2D and here's the MLO tomo.

Here comes the irregular mass that we could see on 2D
and I'm gonna go backwards for you
to show you that here.
Do you believe it? There's another lesion right here.
There's lines coming out of here.

This patient with the dense pattern, she's only 41.
We saw one lesion on 2D
and then we're able to identify possibly a second
lesion on the tomo.

I'm gonna go back again.
One lesion and something else going on here more anteriorly.

Here is just this lesion here
and this area and then on the MLO here
and there more subtle
but something going on more anteriorly.

We felt after we looked at this
that there was more there on MRI.
This patient has quite a bit.

The lesions that we ended up identifying
as cancer and biopsied under ultrasound,
she also had additional linear area
of enhancement up to the nipple.

This young patient was basically kind of full
of cancer in that upper inner quadrant.

Implementation Protocols and Q&A

I do 2D and then I give it a BI-RADS zero.
The patient has to come back for extra views. Can do that?
Yeah.

What we've been doing
because, it all depends
how you start your implementation.
If you switch all your units
to tomo then you're gonna be doing tomo and everybody.

But if you just start slowly with one unit
or two units, everyone can't go
to tomo to start out with.

We came up with a protocol
baseline mammograms in our young patients,
strong family history of breast cancer, young women
with dense breasts.
Personal history of breast cancer or AI.
We try to steer those towards tomo screening.

But there are many other patients that for some reason
or another the units were busy,
they weren't high enough risk so they had a 2D.

When the patient comes back,
'cause we recalled her, if we do have that question along
with our magnification or spot
or roll view, we will get an additional 2D view.

If they're high risk right
and you don't feel comfortable, like I showed you
so many cases it was so hard to see on the 2D I understand
what you're saying or we couldn't see it on the 2D.

In those cases, if they qualify for MRI,
if you have a genetic counselor, you refer patients
with high risk on to genetic testing or to MRI.
If they're 20%
or more lifetime breast cancer risk, I would go that way.

If they're not and they just have dense breasts,
then you recommending your report,
additional screening ultrasound may
be helpful in this patient.

'Cause if you are, if you sent the patient out
and you didn't do tomo wouldn't give her a BI-RADS zero
and just recall for tomo, no I wouldn't do that.

But you can try to capture those dense breasted patients in
your practice initially.
If those patients have been to you before
and they have dense breasts
and you'd like them to have tomo, you have
to have a way to identify them.
Whether having a technologist or your assistant
or someone look at what their density was last year
and then send those patients on
to tomo when they come through your doors.

Logistically for us doesn't work
because we have over 300 patients
and we only have four tomo units.
It doesn't quite work that all of them go through tomo.

Yes you can. Absolutely.

If you are like okay I'm just not gonna do that 2D spot,
I just wanna do that tomo spot, you can try
and see how comfortable you are reading, you know,
going from 2D to 3D plus just an extra view tomo.

But you can do spots. Yes those spots not that right?
Absolutely. And we have evolved
to doing some of that also.

But in the beginning as we were learning, we were going back
to what we're comfortable with, which was our 2D workup.
We would always start with that
and then evolve with the tomo
and increase as we felt more comfortable.

You do have to understand that we're trying
to put ourselves out of business
with everything we do, right?

There's no CAD for tomo.
If we go to see view
and there's no CAD, there's no reimbursement for that,
there's no reimbursement for tomo for most of us
unless you choose to charge the patient,
which some sites have been doing with success.

But with Medicare guidelines now
and what they have put on their site as of January saying
that neuro tomo is part of the 2D mammogram, I
don't think you really can charge the patient for any
of those, for the Medicare population.

Soon excels and all the other insurers will have the
same exact guidelines.

I do think that facilities are trying to in,
be safe and not miss anything.
They go back to what they're familiar with,
which is the 2D spot views and then add the tomo
and get comfortable looking at it side by side
to see if it answers the questions.

I think there are some helpful situations
where 2D is important for calcifications.
I think you do need to magnify, the 2D
because you're gonna lose the forest
for the trees if you just go based on the tomo.
'Cause you don't, you can't see all levels, you know,
you gotta play with your slab back and forth.

I think for calcium it's important.
I was saying to someone else that,
there's some cases where the spot may answer the question.
It truly is abnormal, you know,
and you can find it easily that way.

But yeah, I think ultrasound for most of these patients, we
would go to ultrasound anyway,
especially in the dense breast when we don't,
we're on the fence and we're not sure.