The Effect of Digital Breast Tomosynthesis on BI-RADS Categorization in Different Breast Densities: A Retrospective Evaluation
Methods: In this retrospective study, 520 female patients aged 35–85 years who underwent both MMG and DBT between 2023 and 2025 were included. Standard craniocaudal (CC) views were acquired for MMG and mediolateral oblique (MLO) views for DBT. Synthetic MLO (sMLO) images were automatically generated by the device from DBT data. Patients were categorized according to the breast density (Type A–D), and all images were reviewed in consensus by two experienced radiologists. Breast Imaging Reporting and Data System (BI-RADS) categories, lesion types, were recorded. BI-RADS categorizations from MMG and DBT were compared overall and within density subgroups.
Results: The mean age was 53.0 ± 9.9 years. Breast density distribution was: Type A (3.8%, n=20), B (28.5%, n= 148), C (43.5%, n=226), and D (24.2%, n=126). BI-RADS classifications differed significantly between MMG and DBT, especially in dense breasts. Of the BI-RADS 2 cases on MMG, 21.6% (n=64) were reclassified as BI-RADS 3 or 4 with DBT, while 6.3% (n=7) of BI-RADS 3 cases were downgraded. BI-RADS 5 categorization showed complete agreement between modalities, though 33% (n=5) of BI-RADS 4 cases were downgraded. At least one pathological finding was observed in 91.3% (n=475) of patients, most commonly nodular opacities (57.1%, n=297), vascular wall calcifications (13.3%, n=69), and coarse calcifications (5.4%, n=28). McNemar analysis revealed significant reclassification between BI-RADS 2 and 3 in Types C and D (P<0.001).
Conclusions: DBT significantly alters BI-RADS categorization in dense breasts. These findings support the potential role of DBT as a complementary tool in screening protocols, particularly for patients with heterogeneously dense or extremely dense breast tissue.
1. Arnold M, Morgan E, Rumgay H, et al. Current and future burden of breast cancer: Global statistics for 2020 and 2040. Breast. 2022;66:15-23. doi: 10.1016/j.breast.2022.08.010.
2. Ren W, Chen M, Qiao Y, Zhao F. Global guidelines for breast cancer screening: A systematic review. Breast. 2022;64:85-99. doi: 10.1016/j.breast.2022.04.003.
3. Brown AL, Vijapura C, Patel M, De La Cruz A, Wahab R. Breast Cancer in Dense Breasts: Detection Challenges and Supplemental Screening Opportunities. Radiographics. 2023;43(10):e230024. doi: 10.1148/rg.230024.
4. Gao Y, Moy L, Heller SL. Digital Breast Tomosynthesis: Update on Technology, Evidence, and Clinical Practice. Radiographics. 2021;41(2):321-337. doi: 10.1148/rg.2021200101.
5. Raichand S, Blaya-Novakova V, Berber S, Livingstone A, Noguchi N, Houssami N. Digital breast tomosynthesis for breast cancer diagnosis in women with dense breasts and additional breast cancer risk factors: A systematic review. Breast. 2024;77:103767. doi: 10.1016/j.breast.2024.103767.
6. Chae EY, Kim HH, Cha JH, Shin HJ, Choi WJ. Detection and characterization of breast lesions in a selective diagnostic population: diagnostic accuracy study for comparison between one-view digital breast tomosynthesis and two-view full-field digital mammography. Br J Radiol. 2016;89(1062):20150743. doi: 10.1259/bjr.20150743.
7. Houssami N, Skaane P. Overview of the evidence on digital breast tomosynthesis in breast cancer detection. Breast. 2013;22(2):101-108. doi: 10.1016/j.breast.2013.01.017.
8. Gilbert FJ, Tucker L, Young KC. Digital breast tomosynthesis (DBT): a review of the evidence for use as a screening tool. Clin Radiol. 2016;71(2):141-150. doi: 10.1016/j.crad.2015.11.008.
9. Caumo F, Zorzi M, Brunelli S, et al. Digital Breast Tomosynthesis with Synthesized Two-Dimensional Images versus Full-Field Digital Mammography for Population Screening: Outcomes from the Verona Screening Program. Radiology. 2018;287(1):37-46. doi: 10.1148/radiol.2017170745.
10. Couto HL, Gargano LP, de Oliveira VM, et al. Cost-Effectiveness Analysis of Digital Breast Tomosynthesis Added to Synthetic Mammography in Breast Cancer Screening in Brazil. Pharmacoecon Open. 2024;8(3):403-416. doi: 10.1007/s41669-023-00470-7.
11. American College of Radiology (n.d.) BI-RADS Reporting System. Available from: https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Reporting-and-Data-Systems/BI-RADS Accessed 27 Jul 2025
12. Rafferty EA, Park JM, Philpotts LE, et al. Diagnostic accuracy and recall rates for digital mammography and digital mammography combined with one-view and two-view tomosynthesis: results of an enriched reader study. AJR Am J Roentgenol. 2014;202(2):273-281. doi: 10.2214/AJR.13.11240.
13. Rizuana IH, Leong MH, Tan GC, Isa ZM. Association Between Microcalcification Patterns in Mammography and Breast Tumors in Comparison to Histopathological Examinations. Diagnostics (Basel). 2025;15(13):1687. doi: 10.3390/diagnostics15131687.
14. Huang H, Scaduto D, Plaunova A, Rinaldi K, Fisher PR, Zhao W. Comparison of lesion detection and conspicuity between narrow-angle and wide-angle digital breast tomosynthesis for dense and non-dense breasts. J Med Imaging (Bellingham). 2023;10(Suppl 2):S22407. doi: 10.1117/1.JMI.10.S2.S22407.
15. Lynge E, Vejborg I, Andersen Z, von Euler-Chelpin M, Napolitano G. Mammographic Density and Screening Sensitivity, Breast Cancer Incidence and Associated Risk Factors in Danish Breast Cancer Screening. J Clin Med. 2019;8(11):2021. doi: 10.3390/jcm8112021.
16. Ciatto S, Houssami N, Bernardi D, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583-589. doi: 10.1016/S1470-2045(13)70134-7.
17. Skaane P, Bandos AI, Gullien R, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47-56. doi: 10.1148/radiol.12121373.
18. Kassis I, Lederman D, Ben-Arie G, Giladi Rosenthal M, Shelef I, Zigel Y. Detection of breast cancer in digital breast tomosynthesis with vision transformers. Sci Rep. 2024;14(1):22149. doi: 10.1038/s41598-024-72707-2.
19. Li J, Zhang H, Jiang H, et al. Diagnostic Performance of Digital Breast Tomosynthesis for Breast Suspicious Calcifications From Various Populations: A Comparison With Full-field Digital Mammography. Comput Struct Biotechnol J. 2018;17:82-89. doi: 10.1016/j.csbj.2018.12.004.
20. Mathew B. Effectiveness of psychological intervention package on anxiety and wellness level among patients with anxiety disorders. J Family Med Prim Care. 2022;11(11):6704-6713. doi: 10.4103/jfmpc.jfmpc_561_21.
21. Hadadi I, Clarke J, Rae W, McEntee M, Vincent W, Ekpo E. Reducing Unnecessary Biopsies Using Digital Breast Tomosynthesis and Ultrasound in Dense and Nondense Breasts. Curr Oncol. 2022;29(8):5508-5516. doi: 10.3390/curroncol29080435.
22. Ho TH, Bissell MCS, Kerlikowske K, et al. Cumulative Probability of False-Positive Results After 10 Years of Screening With Digital Breast Tomosynthesis vs Digital Mammography. JAMA Netw Open. 2022;5(3):e222440. doi: 10.1001/jamanetworkopen.2022.2440.
Copyright (c) 2026 The European Research Journal
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Downloads
Article Information
- Article Type Research Article
- Submitted February 21, 2026
- Published March 14, 2026
- Issue 2026: Online First
- Section Research Article
