During the analyzed period, 101 women were invited for supplementary diagnostics (7%). In 51 women, only ultrasound (US) examinations were performed, and BI-RADS 2 or suspicious for malignancy findings obtained. 1 woman had a highly suspicious mass detected in the other breast. 

Case 1: Screening mammogram (2D) of a 65-year-old-woman, shows low-intensity mass posterior in the outer quarter of the right breast. Mammogram with tomosynthesis very clearly shows the spiculated mass. Ultrasound reveals hypoechoic irregular mass with infiltrative features in the lower outer quarter of the right breast. US CNB and after surgery histopathologically confirmed CDI, 13mm, G2, ER: 8, PR: 5, HER2: 0, Ki67: 5%, ln 0/1.

Fig 3: Case 1: a) Screening mammogram (2D) of a 65-year-old-woman, shows low-intensity mass posterior in the outer quarter of the right breast; b) Mammogram with tomosynthesis very clearly shows the spiculated mass; c) Magnification; d) Ultrasound reveals hypoechoic irregular mass with infiltrative features in the lower outer quarter of the right breast. US CNB: CDI, 13mm, G2, ER: 8, PR: 5, HER2: 0, Ki67: 5%, ln 0/1.

This woman had a highly suspicious mass detected in the other breast: 

Case 2: Screening mammogram (2D) of a 65-year-old-woman, left breast, shows no masses or architectural distortions, but 3D mammogram more clearly shows the small spiculated mass. Ultrasound reveals small hypoechoic irregular mass with infiltrative features in the upper outer quarter of the left breast. After surgery histopathologically confirmed CDI, 6mm, G2, ER: 8, PR: 5, HER2: 0, Ki67: 5%, ln 0/1.

Fig 4: Case 2: a) Screening mammogram (2D) of a 65-year-old-woman, left breast, shows no masses or architectural distortions; b) Mammogram with tomosynthesis more clearly shows the small spiculated mass; c) Magnification; d) Ultrasound reveals small hypoechoic irregular mass with infiltrative features in the upper outer quarter of the left breast. After surgery histopathologically confirmed CDI, 6mm, G2, ER: 8, PR: 5, HER2: 0, Ki67: 5%, ln 0/1.

In 21 women, only DBT was performed, resulting in a BI-RADS 2 findings: 

Case 3: Normal screening mammogram (CR) of a 64-year-old-woman. Next regular mammogram with magnification 2 years later shows architectural distortion in the upper quarter of the left breast. There is no architectural distortion on the mammogram with tomosynthesis.

Fig 5: Case 3: a) Normal screening mammogram (CR) of a 64-year-old-woman; b) Next regular mammogram with magnification 2 years later shows architectural distortions in the upper quarter of the left breast; c) There is no architectural distortion on the mammogram with tomosynthesis.

In 29 women, DBT and US was performed, resulting in BI-RADS 2 findings for 18 women;

1 woman had another highly suspicious mass detected in the same breast:

Case 4: Screening mammogram (CR) of a 59-year-old-woman, with normal findings. Next regular screening mammogram (2D) 8 years later shows spiculated mass posterior in the left breast. Mammogram with tomosynthesis reveals another small spiculated mass, anterior in the outer quarter of the same breast. Ultrasound reveals small hypoechoic irregular mass with infiltrative features, anterior in the left breast. US CNB of the larger lesion confirmed CDI, G2, ER: 8, PR: 6, HER2: 1+, Ki67: 5%, and smaller lesion will be histopathologically confirmed after surgery.

Fig 6: Case 4: a) Screening mammogram (CR) of a 59-year-old-woman, with normal findings; b) Next regular screening mammogram (2D) 8 years later shows spiculated mass posterior in the left breast; c) CC projection of the left breast, synthetic 2D image (IN 2D); d) Mammogram with tomosynthesis reveals another small spiculated mass, anterior in the outer quarter of the same breast. US CNB of the larger lesion: CDI, G2, ER: 8, PR: 6, HER2: 1+, Ki67: 5%.

Fig 7: Case 4: a) Next regular screening mammogram (2D) 8 years later shows spiculated mass posterior in the left breast; b) Mammogram with tomosynthesis reveals another small spiculated mass, anterior in the outer quarter of the same breast.; c) Magnification; d) Ultrasound reveals small hypoechoic irregular mass with infiltrative features, anterior in the left breast. This lesion will be histopathologically confirmed after surgery.

9 women had highly suspicious findings for malignancy:

Case 5: Screening mammogram (2D) with magnification (Flavor 0) of a 54-year-old-woman, shows small low-intensity irregular mass posterior in the upper quarter of the left breast. Additional 2D mammogram with magnification (Flavor 1)- the lateral extension of the CC (XCCL view) projection of the left breast- clearly shows small irregular mass posterior in the outer quarter of the left breast. Ultrasound reveals hypoechoic irregular mass with infiltrative features in the upper outer quarter of the left breast. After US CNB and surgery was confirmed CDI, 11mm, G2, ER: 7, PR: 8, HER2: 1+, Ki67: 5%, ln 2/14.

Fig 8: Case 5: a) Screening mammogram (2D) with magnification (Flavor 0) of a 54-year-old-woman, shows small low-intensity irregular mass posterior in the upper quarter of the left breast; b) Additional 2D mammogram with magnification (Flavor 1)- the lateral extension of the CC projection of the left breast clearly shows small irregular mass posterior in the outer quarter of the left breast; c) CC projection of the left breast, synthetic 2D image (IN 2D).

Fig 9: Case 5: a) Screening mammogram (2D) with magnification (Flavor 0) of a 54-year-old-woman, shows small low-intensity irregular mass posterior in the upper quarter of the left breast; b) Mammogram with tomosynthesis more clearly shows the spiculated mass; c) Ultrasound reveals hypoechoic irregular mass with infiltrative features in the upper outer quarter of the left breast. US CNB: CDI, 11mm, G2, ER: 7, PR: 8, HER2: 1+, Ki67: 5%, ln 2/14.

Among the 50 women who underwent DBT, 39 had BI-RADS 2 category, meaning that 62 women would have been called for additional diagnostics if the screening was performed by tomosynthesis, which would reduce the recall rate from 7% to 4.3%.