The role and potential of digital breast tomosynthesis in neoadjuvant systemic therapy evaluation for optimising breast cancer management: a pictorial essay

Neoadjuvant therapy (NT) has become the gold standard for treating locally advanced breast cancer (BC). The assessment of pathological response (pR) post-NT plays a crucial role in predicting long-term survival, with contrast-enhanced MRI currently recognised as the preferred imaging modality for its evaluation. Traditional imaging techniques, such as digital mammography (DM) and ultrasonography (US), encounter difficulties in post-NT assessments due to breast density, lesion changes, fibrosis, and molecular patterns. Digital breast tomosynthesis (DBT) offers solutions to prevalent challenges in DM, such as tissue overlap, and facilitates a comprehensive assessment of lesion morphology, dimensions, and margins. Studies suggest that DBT correlates more accurately with pathology than DM and US, showcasing its potential advantages. This pictorial essay demonstrates the potential of DBT as a complementary tool to DM for assessing pR after NT, including instances of true- and false-positive assessments correlated with histopathological findings. In conclusion, DBT emerges as a valuable adjunct to DM, effectively addressing its limitations in post-NT assessment. The technology's potential to diminish tissue overlap, improve discrimination, and provide multi-dimensional perspectives demonstrates promising results, indicating its utility in scenarios where MRI is contraindicated or inaccessible.