European Journal of Radiology 84 (2015) 10121018

Contents lists available at ScienceDirect

European Journal of Radiology

journal homepage: www.elsevier.com/locate/ejrad

The value of digital tomosynthesis of the chest as a problem-solving

tool for suspected pulmonary nodules and hilar lesions detected on
chest radiography
Angela Galea a, , Paul Dubbins b,1 , Richard Riordan b,1 , Tarig Adlan b,1 ,
Carl Roobottom b,1 , David Gay b,1
a
b

Peninsula Radiology Academy, William Prance Road, Plymouth PL65WR, UK

Plymouth Hospital NHS Trust, Plymouth PL68DH, UK

a r t i c l e

i n f o

Article history:
Received 2 June 2014
Received in revised form
28 November 2014
Accepted 9 February 2015
Keywords:
Digital tomosynthesis
Chest radiology
Lung nodules
Hilar lesions

a b s t r a c t
Objectives: To assess the capability of digital tomosynthesis (DTS) of the chest compared to a posteroanterior (PA) and lateral chest radiograph (CXR) in the diagnosis of suspected but unconrmed pulmonary
nodules and hilar lesions detected on a CXR. Computed tomography (CT) was used as the reference
standard.
Materials and method: 78 patients with suspected non-calcied pulmonary nodules or hilar lesions on
their CXR were included in the study. Two radiologists, blinded to the history and CT, prospectively
analysed the CXR (PA and lateral) and the DTS images using a picture archiving and communication
workstation and were asked to designate one of two outcomes: true intrapulmonary lesion or false
intrapulmonary lesion. A CT of the chest performed within 4 weeks of the CXR was used as the reference
standard. Inter-observer agreement and time to report the modalities were calculated for CXR and DTS.
Results: There were 34 true lesions conrmed on CT, 12 were hilar lesions and 22 were peripheral nodules.
Of the 44 false lesions, 37 lesions were artefactual or due to composite shadow and 7 lesions were real
but extrapulmonary simulating non-calcied intrapulmonary lesions. The PA and lateral CXR correctly
classied 39/78 (50%) of the lesions, this improved to 75/78 (96%) with DTS. The sensitivity and specicity
was 0.65 and 0.39 for CXR and 0.91 and 1 for DTS. Based on the DTS images, readers correctly classied
all the false lesions but missed 3/34 true lesions. Two of the missed lesions were hilar in location and
one was a peripheral nodule. All three missed lesions were incorrectly classied on DTS as composite
shadow.
Conclusions: DTS improves diagnostic condence when compared to a repeat PA and lateral CXR in the
diagnosis of both suspected hilar lesions and pulmonary nodules detected on CXR. DTS is able to exclude
most peripheral pulmonary nodules but caution and further studies are needed to assess its ability to
exclude hilar lesions.
2015 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Despite the inferior performance of chest radiography (CXR) to
computed tomography (CT) scanning it remains the initial examination for the majority of pulmonary disease due to its low cost,
easy access and low radiation dose. Obvious pulmonary lesions

Corresponding author. Tel.: +44 7800511681.

E-mail addresses: galeaangie@gmail.com (A. Galea), Paul.dubbins@nhs.net
(P. Dubbins), richardriordan@nhs.net (R. Riordan), tarig.adlan@nhs.net (T. Adlan),
carl.roobotoom@nhs.net (C. Roobottom), davegay@nhs.net (D. Gay).
1
Tel.: +44 1752437437.
http://dx.doi.org/10.1016/j.ejrad.2015.02.007
0720-048X/ 2015 Elsevier Ireland Ltd. All rights reserved.

detected on CXR clearly need further investigation and CT scanning

is recommended. Chest radiography however has a low sensitivity
and specicity for the detection of early lung cancer [1]. Lung cancer
is the leading cause of cancer globally and is associated with poor
outcome [24]. However the 2011 US National Lung Screening Trial
demonstrated that early detection reduces mortality and emphasizes the need to detect early cancer [5]. Small pulmonary nodules
carry a low risk of lung cancer but may require further investigation and often patients with lung nodules undergo CT scanning
for evaluation. Alternative investigations, without the high cost or
radiation dose of CT scanning that offer increased accuracy in pulmonary and hilar lesions suspicious for cancer would be useful in
the investigation of pulmonary disease.

A. Galea et al. / European Journal of Radiology 84 (2015) 10121018

Table 1
The various indications for referral for a chest radiograph. Some patients were
referred for more than one symptom.
Indication

In-patient
N = number of
patients

Out-patient
N = number of
patients

Cough
Shortness of breath
Chest pain
Infection
Arrythmia
Other (e.g. weight loss, arthritis)

3
3
4
1
2
4

29
21
8
3
2
10

A radiologist will frequently identify a small group of CXRs that

are equivocal either because of an inability to correctly characterise
a visualised abnormality as soft tissue or calcied and therefore
likely benign or an inability to determine the location of the lesion
as intra- or extrapulmonary. The radiologist may be unsure whether
a lesion is real or composite especially if it lies in a region of heavy
anatomical noise such as the lung hila or apices. Patients with
equivocal CXRs due to one of the above ndings were included
in the study to assess the role of digital tomosynthesis (DTS) in
conrming or excluding a potentially signicant abnormality.
DTS is a type of limited angle tomography whereby about sixty
low dose images are acquired over a limited range of X-ray tube
movement in the cranio-caudal axis. The raw images are used to
reconstruct contiguous coronal images in the antero-posterior axis
through the area of interest. Tomosynthesis evolved from the technique of tomography, which was used to evaluate, inter alia the lung
hila, the kidneys and the petrous temporal bones. Increasing concern about the patient dose from CT has resulted in a resurgence of
interest in tomographic techniques such as tomosynthesis because
of the associated low radiation dose.
Digital tomosynthesis reduces composite artefact due to
anatomical noise by providing better depth resolution thus separating the structures in the antero-posterior dimension. DTS can
correctly differentiate between lesions of the rib cage, pleurally
based lesions and intrapulmonary lesions [613]. Improved contrast resolution of DTS when compared to CXR results in better
calcium detection [13]. Advantages when compared to CT relate to
cost and dose reduction.
The role of DTS in the evaluation of pulmonary nodules has
been explored in previous studies [1416]. In this study we chose a
more pragmatic approach by assessing both non-calcied intrapulmonary nodules and hilar masses using CT as the gold standard. The
purpose of this study is to assess whether DTS can be used instead
of a repeat PA and lateral chest radiograph in the evaluation of an
equivocal chest radiograph.
2. Method
2.1. Patients
The study was approved by the regional ethics committee. This
was a single centre, prospective observational study. All inpatients
and outpatients with an equivocal nding on chest radiograph were
included. The indications for the initial chest radiograph were varied so as to simulate clinical practice and are shown in Table 1. All
patients included in the study consented to have a repeat PA and
lateral CXR, a DTS and a CT chest within 4 weeks of their initial CXR.
2.2. Digital tomosynthesis
A General Electric (GE, Buc, France) VolumeRAD system with a
high-quality digital detector with rapid read-out was used, which
relies on the GE Denium 8000 digital X-ray system to acquire the

1013

projection images necessary for tomosynthesis reconstruction. A

scout image of the chest is rst obtained to conrm a correct position. The patient is then instructed to hold his/her breath for 10 s
whilst 60 discrete images are acquired over an angular range of
35 to produce 5060 coronal reconstructions of the chest. The
tube voltage was set at 120 kVp. Each raw image delivers an average effective dose of 2 Sv resulting in a cumulative effective dose
of 0.15 mSv for the average 70 kg male patient (this effective dose
includes both the scout and raw images).
2.3. Computed tomography
The CT examinations were performed using a 64 slice multidetector (HD750, GE Healthcare) scanner. The scan parameters used
were: a set noise index of 39.68; 120 kV and a range of 100750 mA.
The CT slice thickness was 0.625 mm for all patients. The effective dose (based on an unenhanced scan) was calculated using a
conversion factor from doselength product (DLP) to E (EDLP ) of
0.017 mSv/(mGy cm) and was 4 mSv[17].
Thirty-two patients with suspected hilar lesions were scanned
following an additional 100 mL intravenous bolus injection of iodinated contrast at a rate of 3.5 mL/s. All other patients had an
unenhanced scan of the chest.
2.4. Image interpretation
A nodule was dened according to the Fleischner Society
Glossary of Terms as a rounded opacity, well or poorly dened measuring up to 3 cm in diameter [18]. A hilar lesion for the purpose of
this study was dened as a lesion of any size but within 3 cm of the
hilar point measured in the coronal/antero-posterior (AP) direction.
Hilar lesions included hilar carcinomas, lung nodules within 3 cm
of the hilar point and hilar adenopathy. The hilar point is formed
as the descending superior pulmonary vein crosses anterior to the
interlobar pulmonary artery [19,20].
2.5. Data analysis
Three radiologists with 30, 15 and 10 years experience participated in the study. Two radiologists with 30 and 10 years
experience (reviewers 1 and 2) blinded to the patient history evaluated two series for each patient; one series contained a PA and
lateral CXR whereas the second series contained a DTS of the chest.
The series were randomly allocated with 4 weeks between each
series to minimise recall bias. The time to report both series was
recorded. For those patients with more than one lesion detected
on their CXR and DTS only the most obvious abnormality that was
initially raised as equivocal on their index CXR was analysed. All
other incidental abnormalities were not included in the analysis.
The readers were instructed to classify all intrapulmonary
non-calcied peripheral nodules and hilar lesions as true lesions.
Artefactual, calcied, pleural or extrapulmonary lesions were classied as false lesions as shown in Table 2. Readers were allowed
to use processing tools such as windowing and zooming as they
would in clinical practice. When there was a discrepancy amongst
the readers, a third reader with 15 years experience was asked to
arbitrate the ndings.
The CT images were analysed by a 4th radiologist with 6 years
experience. 0.625 mm CT axial slices, 5 mm maximum intensity
projection (MIP) axial, coronal and sagittal CT reformats were used
to maximise lesion detection. The axial images were used to measure the largest diameter of the detected lesion for analysis. Coronal
CT images were reconstructed for all lesions detected on CT and
these were compared subjectively to the CXR and DTS ndings. Any
lesions detected on CXR and DTS were correlated with the reference
standard CT into true positive and negative and false positive and

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A. Galea et al. / European Journal of Radiology 84 (2015) 10121018

Table 2
The classication of true and false lesions detected on CXR and DTS. The number
of patients is shown in the parenthesis. CT was used as the reference method to
determine the nal diagnoses. n, number of lesions.

Intrapulmonary

True lesion (n)

False lesion (n)

Non-calcied
peripheral nodule (22)
Hilar nodule (7)
Hilar mass (3)
Hilar
lymphadenopathy (1)
Anterior mediastinal
mass (1)

Granuloma (1)
Pseudolesions hilar (19)
Pseudolesions peripheral
(18)

Extrapulmonary

Pleural plaque (3)

Rib lesions (2)
Nipple shadows (1)

negative lesions. A thoracic radiologist with 15 years experience

arbitrated all equivocal lesions.
2.6. Statistical analysis
Differences in the sensitivity and specicity were compared
using McNemars tests, with a p-value of less than 0.05 considered
to be a statistically signicant. Subgroup analysis for non-calcied
pulmonary nodules and hilar masses was performed. Inter-rater
agreement for the two reviewers was assessed using kappa statistics. A kappa statistic of <0.4 was considered to be a fair agreement;
0.40.6 moderate; 0.60.8 good and >0.8 a very good agreement.
All statistical analysis was conducted using the statistical programming language R [21].
3. Results
Seventy-eight patients were included in the study. There were
34 true lesions conrmed on CT, 12 were hilar lesions and 22 were
peripheral nodules. Of the 44 false lesions, 37 lesions were artefactual or due to composite shadow and 7 lesions were real but
extrapulmonary simulating non-calcied intrapulmonary lesions.
Table 2 summarises the nal diagnoses conrmed with CT. The
repeat PA and lateral CXR correctly resolved 39/78 lesions (50%)
whereas DTS resolved 75/78 lesions (96%). Graph 1 shows the percentage number of peripheral nodules, hilar masses and overall
lesions resolved by CXR and DTS.
The sensitivity for CXR and DTS was 0.65 and 0.91 respectively.
This was statistically signicant with a p-value of 0.0265. An example of a nodule that was detected on both modalities is shown in
Fig. 1. The specicity of CXR and DTS was 0.39 and 1 respectively,

Table 3
Sensitivity and specicity for CXR and DTS. Condence intervals are shown in brackets. CXR, chest radiograph including a PA and lateral; DTS, digital tomosynthesis.
Variable (n = 78)
Apparent prevalence
True prevalence
Sensitivity
Specicity
Positive predictive value
Negative predictive value

CXR (95% CI)

0.63 (0.51, 0.74)
0.44 (0.32, 0.55)
0.65 (0.46, 0.8)
0.39 (0.24, 0.55)
0.45 (0.31, 0.6)
0.59 (0.39, 0.76)

DTS (95% CI)

0.4 (0.29, 0.51)
0.44 (0.32, 0.55)
0.91 (0.76, 0.98)
1 (0.88, 1)
1 (0.84, 1)
0.94 (0.82, 0.99)

this showed a clear statistical difference (p-value = <0.5). The sensitivity and specicity results for CXR and DTS are summarised in
Table 3. Of the 39 lesions incorrectly classied on the PA and lateral
CXR, 27 were classied as false positive lesions and 12 were false
negative lesions. Examples of false positive and negative lesions on
CXR are shown in Figs. 2 and 3. There were no false positive lesions
with DTS but three true lesions where incorrectly classied as composite vascular pseudolesions. The incorrectly classied lesions on
DTS include two hilar lung cancers and one peripheral carcinoid
tumour (Fig. 4).
Pseudolesions included composite shadows due to overlying
ribs, vascular structures, cardiac fat pads and pulmonary scarring
simulating a nodule. Of the 34 true lesions conrmed on CT, 15 were
subsequently biopsy-proven lung cancers. Fourteen lesions remain
indeterminate and are still being followed up with interval scans
as per Fleischner Guidelines at the time of writing [22]. Five lesions
were proven benign following biopsy and further imaging such as
PET (Fig. 5).
Eleven of the 15 cancers were detected on CXR and 12 with DTS.
The missed cancers were located in the hila, the apices and the right
mid-zone obscured by composite artefact afforded by the ribs and
vascular structures. Fig. 4 is an example of a peripheral carcinoid
cancer that was detected on CXR but although visible on DTS, was
thought to represent composite vascular shadow.
There were 32 suspected hilar lesions out of the 78 total lesions.
Of these, 12 were true lesions conrmed on CT. Nineteen out of
32 (60%) and 30/32 (94%) were correctly classied on CXR and
DTS respectively as shown in Graph 1. Eleven hilar lesions were
overcalled on CXR and one lesion was missed. There were no false
positives with DTS however 2 lesions were missed. Fig. 5 shows
a left peri-hilar lesion that was missed on both CXR and DTS. The
lesion can be seen on both modalities but is in a region of high
anatomical noise.
Analysis of inter-observer agreement for CXR resulted in kappa
statistics of 0.41 for reviewers 1 and 2, suggesting moderate agreement between the reviewers, this improved to 0.83 for DTS for
reviewers 1 and 2 suggesting very good agreement between the
reviewers. The average time taken to report 78 PA and lateral
CXR examinations was 64 and 67 s for reviewers 1 and 2 (range
30150 s). The average time taken to report a DTS examination was
92 and 172 s for reviewers 1 and 2 respectively (range 45400 s).

4. Discussion

Graph 1. This graph expressed as a percentage shows the number of lesions resolved
by repeat PA and lateral CXR and DTS. There were 32 suspected hilar masses, 46
peripheral nodules and 78 lesions overall.

The aim of this study was to assess the clinical usefulness of DTS
as an adjunct to CXR and instead of a repeat PA and lateral CXR for
the detection of suspected but unconrmed intrapulmonary and
hilar lesions. Previous studies have demonstrated that DTS is superior to CXR for the detectability of pulmonary nodules [14,15,23]
however these studies did not include hilar lesions.
In this study DTS resolved the majority of suspected pulmonary
nodules and hilar lesions with a clear improvement in specicity
and inter-reader agreement when compared to a PA and lateral
CXR. CT has a signicantly better sensitivity than either CXR or

A. Galea et al. / European Journal of Radiology 84 (2015) 10121018

1015

Fig. 1. A 44-year-old gentleman was referred for a CXR due to a persistent cough. (a) The PA CXR shows an ill-dened opacity in the right lower zone. (b) The lateral CXR
demonstrates a nodule below the hilum. (c) The DTS image conrms that the nodule is intrapulmonary. The nodule was FDG negative and did not change over a period of 18
months and is most likely in keeping with a benign hamartoma.

Fig. 2. A 58-year-old gentleman presented with a 4-week history of a cough. (a) The CXR shows 2 ill-dened nodules. The lesion marked 1 was detected on the initial CXR,
lesion 2 was an incidental nding. (b) The DTS image shows lesion 1 is not intrapulmonary and is in keeping with a sclerotic focus within the 4th anterior rib. (c) DTS image
with the anterior pleura in focus demonstrates lesion 2 is in keeping with a subpleural nodule.

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A. Galea et al. / European Journal of Radiology 84 (2015) 10121018

Fig. 3. A 65-year-old gentleman was referred for a CXR due to shortness of breath. (a) The CXR shows a prominent right hilum. (b) The DTS image was acquired on the same
day as the CXR and demonstrates right hilar and tracheobronchial nodularity in keeping with sarcoidosis.

DTS and its role in the evaluation of an unequivocally abnormal

radiograph is well established and not challenged by DTS.
The specicities for CXR and DTS were 39% and 100% respectively in our study. Quaia et al. have reported similar specicities
of 1336% and 9095% for CXR and DTS respectively in patients
with suspected pulmonary lesions [2426]. These results demonstrate that the specicity of DTS is similar to CT in this pre-selected
group of patients. This suggests that the true value of DTS lies
in its negative predictive value, or rather in its ability to exclude
a suspected lesion. DTS classied 47 out of the 78 suspected

lesions as false. Before DTS was introduced, these 47 patients

would have been referred for a CT chest in our institution in
view of the equivocal CXR ndings. Only 3/47 lesions were positive, therefore we could infer that by including DTS in the
patient pathway we can avoid 47 CT scans (60%) in this cohort
of patients with many advantages not least a reduction in patient
ionisation dose. However, a further 27 incidental lesions were
detected in the 47 patients on DTS and therefore some of these
patients may require a CT for further evaluation of these incidental
lesions.

Fig. 4. A 55-year-old lady was referred for a CXR due to right pleuritic chest pain. The nodule in the right cardiophrenic angle was detected on CXR but missed on DTS. (a, b)
CXR and DTS images demonstrate the right cardiophrenic angle nodule. (c) The axial CT with fused PET image demonstrates mild tracer uptake in the nodule. The patient
had a lobectomy and the histology was in keeping with carcinoid tumour.

A. Galea et al. / European Journal of Radiology 84 (2015) 10121018

1017

Fig. 5. A 66-year-old lady was a heavy smoker. She was referred by her GP for a CXR in view of a hoarse voice. (a) The CXR shows an ill-dened left perihilar lesion that was
missed on CXR. (b) The DTS image again demonstrates the mass abutting the descending thoracic aorta. This was detected by one reviewer but was thought to represent
composite vascular shadow by a third radiologist who arbitrated the nding. (c) The axial CT with fused PET demonstrates an active metabolic tumour in this region. This
was biopsy-proven non-small cell lung cancer.

The evaluation of the lung hila is a challenging task for thoracic

radiologists. In a UK audit assessing the retrospective diagnosis
of missed lung cancer on 4452 chest radiographs, hilar lesions
accounted for most of the misses with 42% of missed lung cancers located in the lung hila [27]. Ten of the 12 hilar lesions were
detected with DTS and there were no false positives with DTS when
compared to 11 with CXR. To our knowledge, this is the rst study to
assess the accuracy of DTS for suspected hilar lesions. These results
suggest that detection of hilar lesions is not improved with DTS
however DTS is more specic. Our numbers are small, however, we
can infer that the role of DTS lies with problem-solving rather than
detecting an abnormal lung hilum on CXR.
DTS is unlikely to be adopted as an alternative to CXR for all but
a few pre-selected patient populations. DTS has been evaluated in
several pre-selected patient groups: in patients with known lung
nodules the detection rate of CXR and DTS respectively has been
shown to lie between 1622% and 5670% [14,23]; in the followup of patients with colorectal cancer the detection rate of lung
nodules with DTS was higher at 87% however calcied granulomas were included as positive lesions in this study and this may
have increased the detection rate [10]; Terzi et al. are evaluating
the role of DTS as a screening tool for lung cancer in smokers [28].
The sensitivity for DTS in our study was 91% and this compares well
with 8595% [24,25] quoted in the literature in a similar patient
group. These results infer that DTS has the best value in patients
with suspected but unconrmed pulmonary lesions.
DTS is not without disadvantages, the hardware is more expensive [29] and while reporting time, though short, is twice that of
CXR (average reporting times of 134 vs. 64 s respectively). The ionisation dose of DTS (0.15 mSv) is a fraction of the dose of a CT chest
(4 mSv). Furthermore, DTS is a relatively new technique and there is
potential for further dose optimisation. Hwang et al. [30] described
a low dose setting for tomosynthesis resulting in a dose reduction
of 67%. This reduction in dose produces an effective dose similar to
that of a two-view CXR (PA and lateral). Further reduction in dose
for DTS using techniques such as adaptive statistical reconstruction
(ASIR) is possible in the future.

5. Conclusion
In this study we have evaluated the role of DTS as a
problem-solving tool for patients with suspected but unconrmed
pulmonary nodules or hilar lesions on their CXR. The low radiation dose for digital tomosynthesis and the relatively short time
taken to report a DTS make it an attractive alternative to a repeat
PA and lateral chest radiograph. DTS demonstrates clear improvements in sensitivity, inter-reader agreement and specicity when
compared to PA and lateral CXR for the evaluation of the equivocal
CXR. We propose that DTS can be used instead of a repeat PA and lateral CXR to problem-solve an equivocal CXR in patients with a low
index of suspicion of a lung nodule or hilar lesion. Whilst DTS can
exclude most peripheral lesions it is less accurate for hilar lesions
and further studies are needed.
Conicts of interest
The authors have no conicts of interest and no disclosures.
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