Evaluation of contrast-enhanced digital mammography

The Correlation between Morpho-Dynamic Contrast-Enhanced Mammography (CEM) Features and Prognostic Factors in Breast Cancer: A Single-Center Retrospective Analysis

Breast cancer, a major contributor to female mortality globally, presents challenges in detection, prompting exploration beyond digital mammography. Contrast-Enhanced Mammography (CEM), integrating morphological and functional information, emerges as a promising alternative, offering advantages in cost-effectiveness and reduced anxiety compared to MRI. This study investigates CEM's correlation with breast cancer prognostic factors, encompassing histology, grade, and molecular markers. In a retrospective analysis involving 114 women, CEM revealed diverse lesion characteristics. Statistical analyses identified correlations between specific CEM features, such as spiculated margins and irregular shape, and prognostic factors like tumor grade and molecular markers. Notably, spiculated margins predicted lower grade and HER2 status, while irregular shape correlated with PgR and Ki-67 status. The study emphasizes CEM's potential in predicting breast cancer prognosis, shedding light on tumor behavior. Despite the limitations, including sample size and single-observer analysis, the findings advocate for CEM's role in stratifying breast cancers based on biological characteristics. CEM features, particularly spiculated margins, irregular shape, and enhancement dynamics, may serve as valuable indicators for personalized treatment decisions. Further research is crucial to validate these correlations and enhance CEM's clinical utility in breast cancer assessment.

Iopromide for Contrast-Enhanced Mammography: A Systemic Review and Meta-Analysis of Pertinent Literature

Background

Contrast-enhanced mammography (CEM) is an emerging breast imaging modality. Clinical data is scarce.

Objectives

To summarize clinical evidence on the use of iopromide in CEM for the detection or by systematically analyzing the available literature on efficacy and safety.

Design

Systematic review and meta-analysis.

Data sources and methods

Iopromide-specific publications reporting its use in CEM were identified by a systematic search within Bayer's Product Literature Information (PLI) database and by levering a recent review publication. The literature search in PLI was performed up to January 2023. The confirmatory-supporting review publication was based on a MEDLINE/EMBASE + full text search for publications issued between September 2003 and January 2019. Relevant literature was selected based on pre-defined criteria by 2 reviewers. The comparison of CEM vs traditional mammography (XRM) was performed on published results of sensitivity and specificity. Differences in diagnostic parameters were assessed within a meta-analysis.

Results

Literature search: A total of 31 studies were identified reporting data on 5194 patients. Thereof, 19 studies on efficacy and 3 studies on safety. Efficacy: in 11 studies comparing iopromide CEM vs XRM, sensitivity was up to 43% higher (range 1%-43%) for CEM. Differences in specificity were found to be in a range of -4% to 46% for CEM compared with XRM. The overall gain in sensitivity for CEM vs XRM was 7% (95% CI [4%, 11%]) with no statistically significant loss in specificity in any study assessed. In most studies, accuracy, positive predictive value, and negative predictive value were found to be in favor of CEM. In 2 studies comparing CEM with breast magnetic resonance imaging (bMRI), both imaging modalities performed either equally well or CEM tended to show better results with respect to sensitivity and specificity. Safety: eight cases of iopromide-related adverse drug reactions were reported in 1022 patients (0.8%).

Conclusions

Pertinent literature provides evidence for clinical utility of iopromide in CEM for the detection or confirmation of breast cancer. The overall gain in sensitivity for iopromide CEM vs XRM was 7% with no statistically significant loss in specificity.

Evaluation of exposure factors of dual-energy contrast-enhanced mammography to optimize radiation dose with improved image quality

Background

Dual-energy contrast-enhanced mammography (DECEM) is an advanced breast imaging technique of digital mammography.

Purpose

To assess the total radiation dose received from complete DECEM using different combinations of exposure parameters for low- and high-energy images.

Materials and methods

A dedicated phantom with three different concentrations of iodine inserts was used. Each iodine insert was 10 mm in diameter and concentration of 1.0 mgI/cm³, 2.0 mgI/cm³, and 4.0 mgI/cm³. The phantom was exposed at varying kVp levels. Mean glandular dose (MGD) was estimated. Contrast to noise ratio (CNR) and figure of merit (FOM) of the iodine inserts were used to assess the image quality.

Results

The optimum CNR of the recombined images was obtained by using 28 kVp + 49 kVp tube voltage combination for 50 mm thickness, 50% fibroglandular phantom only with a 26% dose increase compared to the highest voltages (32 kVp + 49 kVp) that can be used for low energy (LE) and high energy (HE) imaging. The CNR value was increased with increasing iodine concentration (R² > 0.99).

Conclusion

The use of as low as possible tube voltage for the LE imaging of standard 50% fibroglandular–50% adipose, 50 mm thickness breast while using the highest tube voltage for HE imaging has reduced the MGD while keeping optimum image quality.

Contrast-enhanced digital mammography and magnetic resonance imaging: reproducibility compared to pathologic anatomy

PURPOSE

To compare the reproducibility between contrast-enhanced digital mammography (CEDM) and magnetic resonance imaging (MRI) with the postsurgical pathologic examination. In addition, the applicability of the Breast Imaging-Reporting and Data System (BI-RADS) lexicon of MRI to CEDM was evaluated for mass lesions.

METHODS

A total of 62 patients with a histologically proven diagnosis of breast cancer were included in this study, for a total of 67 lesions. Fifty-nine patients underwent both methods. The reproducibility between MRI vs CEDM and the reference standard (postoperative pathology) was assessed by considering the lesion and breast size as pivotal variables. Reproducibility was evaluated by computing the concordance correlation coefficient (CCC). Bland-Altman plots were used to depict the observed pattern of agreement as well as to estimate the associated bias. Furthermore, the pattern of agreement between the investigated methods with regard to the breast lesion characterization (i.e. mass/nonmass; shape; margins; internal enhanced characteristics) was assessed by computing the Cohen kappa and its 95% confidence interval (CI).

RESULTS

The reproducibility between MRI and the reference standard and between CEDM and the reference standard showed substantial agreement, with a CCC value of 0.956 (95% CI, 0.931-0.972) and 0.950 (95% CI, 0.920-0.969), respectively. By looking at the Bland-Altman analysis, bias values of 2.344 and 1.875 mm were observed for MRI and CEDM vs reference evaluation, respectively. The agreement between MRI and CEDM is substantial with a CCC value of 0.969 (95% CI, 0.949-0.981). The Bland-Altman analysis showed bias values of -0.469 mm when comparing CEDM vs MRI. Following the Landis and Koch classification criteria, moderate agreement was observed between the two methods in describing BI-RADS descriptors of mass lesions.

CONCLUSION

CEDM is able to measure and describe tumor masses comparably to MRI and can be used for surgical planning.

Diagnostic Performance of Adjunctive Imaging Modalities Compared to Mammography Alone in Women with Non-Dense and Dense Breasts: A Systematic Review and Meta-Analysis

PURPOSE

To compare the diagnostic performance of mammography (MG) alone versus MG combined with adjunctive imaging modalities, including handheld ultrasound (HHUS), automated breast ultrasound (ABUS), digital breast tomosynthesis (DBT), contrast-enhanced mammography (CEM), and magnetic resonance imaging (MRI) in women with non-dense and dense breasts.

PATIENTS AND METHODS

Medline, Embase, PubMed, CINAHL, Scopus, and the Web of Science databases were searched up to October 2019. Quality assessment was performed using QUADAS-2. RevMan 5.3 was used to conduct a meta-analysis of the studies.

RESULTS

In dense breasts, adding adjunctive modalities significantly increased cancer detection rates (CDRs): HHUS (relative risk [RR] = 1.49; 95% confidence interval [CI], 1.19-1.86; P = .0005); ABUS (RR = 1.44; 95% CI, 1.16-1.78; P = .0008); DBT (RR = 1.38; 95% CI, 1.14-1.67; P = .001); CEM (RR = 1.37; 95% CI, 1.12-1.69; P = .003); and MRI (RR = 2.16; 95% CI, 1.81-2.58; P < .00001). The recall rate was significantly increased by HHUS (RR = 2.03; 95% CI, 1.89-2.17; P < .00001), ABUS (RR = 1.90; 95% CI, 1.81-1.99; P < .00001), and MRI (RR = 2.71; 95% CI, 1.73-4.25; P < .0001), but not by DBT (RR = 1.14; 95% CI, 0.95-1.36; P = .15). In non-dense breasts, HHUS and MRI showed significant increases in CDRs but not DBT: HHUS (RR = 1.14; 95% CI, 1.01-1.29; P = .04); MRI (RR = 1.78; 95% CI, 1.14-2.77; P = .01); and DBT (RR = 1.09; 95% CI, 1.13-1.75; P = .08). The recall rate was also significantly increased by HHUS (RR = 1.43; 95% CI, 1.28-1.59; P < .00001) and MRI (RR = 3.01; 95% CI, 1.68-5.39; P = .0002), whereas DBT showed a non-significant reduction (RR = 0.83; 95% CI, 0.65-1.05; P = .12).

CONCLUSION

Adding adjunctive modalities to MG increases CDRs in women with dense and non-dense breasts. Ultrasound and MRI increase recall rates across all breast densities; however, MRI results in higher values for both CDRs and recall rates.

[Contrast-enhanced mammography]

Early detection is of great importance for the successful treatment of breast cancer and for a good prognosis. Contrast-enhanced mammography and especially contrast-enhanced spectral mammography (CESM) show promising initial results and are a valuable addition to currently available methods. The advantage of these methods is that imaging of both breasts can be performed in a single examination with a single contrast agent application. The accuracy of CESM is similar to that of magnetic resonance imaging (MRI), easily available at low costs, which is why this procedure is increasingly used in the diagnostic work up of breast cancer. CESM is also a good alternative to MRI if this cannot be performed due to contraindications.

Advanced and futuristic approaches for breast cancer diagnosis

Background

Breast cancer is the most frequent cancer and one of the most common causes of death in women, impacting almost 2 million women each year. Tenacity or perseverance of breast cancer in women is very high these days with an extensive increasing rate of 3 to 5% every year. Along with hurdles faced during treatment of breast tumor, one of the crucial causes of delay in treatment is invasive and poor diagnostic techniques for breast cancer hence the early diagnosis of breast tumors will help us to improve its management and treatment in the initial stage.

Main body

Present review aims to explore diagnostic techniques for breast cancer that are currently being used, recent advancements that aids in prior detection and evaluation and are extensively focused on techniques that are going to be future of breast cancer detection with better efficiency and lesser pain to patients so that it helps to a physician to prevent delay in treatment of cancer. Here, we have discussed mammography and its advanced forms that are the need of current era, techniques involving radiation such as radionuclide methods, the potential of nanotechnology by using nanoparticle in breast cancer, and how the new inventions such as breath biopsy, and X-ray diffraction of hair can simply use as a prominent method in breast cancer early and easy detection tool.

Conclusion

It is observed significantly that advancement in detection techniques is helping in early diagnosis of breast cancer; however, we have to also focus on techniques that will improve the future of cancer diagnosis in like optical imaging and HER2 testing.

Contrast-Enhanced Mammography for Screening Women after Breast Conserving Surgery

Simple Summary

Breast cancer survivors are at risk for recurrence, and the early detection of recurrence improves survival. Therefore, imaging surveillance is performed for women who have breast-conserving surgery. The aim of our retrospective study was to compare routine mammography with contrast-enhanced mammography in the screening (asymptomatic) post-treatment setting. We confirmed that when screening women with breast conservation surgery, contrast-enhanced mammography had a higher cancer detection rate (15.4/1000) and positive predictive value of biopsies (42.9%) than full-field digital mammography (6.2/1000 and 37.5%, respectively).

Abstract

To investigate the value of contrast-enhanced mammography (CEM) compared to full-field digital mammography (FFDM) in screening breast cancer patients after breast-conserving surgery (BCS), this Health Insurance Portability and Accountability Act-compliant, institutional review board-approved retrospective, single-institution study included 971 CEM exams in 541 asymptomatic patients treated with BCS who underwent screening CEM between January 2013 and November 2018. Histopathology, or at least a one-year follow-up, was used as the standard of reference. Twenty-one of 541 patients (3.9%) were diagnosed with ipsi- or contralateral breast cancer: six (28.6%) cancers were seen with low-energy images (equivalent to FFDM), an additional nine (42.9%) cancers were detected only on iodine (contrast-enhanced) images, and six interval cancers were identified within 365 days of a negative screening CEM. Of the 10 ipsilateral cancers detected on CEM, four were detected on low-energy images (40%). Of the five contralateral cancers detected on CEM, two were detected on low-energy images (40%). Overall, the cancer detection rate (CDR) for CEM was 15.4/1000 (15/971), and the positive predictive value (PPV3) of the biopsies performed was 42.9% (15/35). For findings seen on low-energy images, with or without contrast, the CDR was 6.2/1000 (6/971), and the PPV3 of the biopsies performed was 37.5% (6/16). In the post-BCS screening setting, CEM has a higher CDR than FFDM.

The accuracy of titanium contrast-enhanced mammography: a retrospective multicentric study

BACKGROUND

Recently, a new mammography system to perform contrast-enhanced mammography has become available in the market. For the high-energy acquisition, it uses a titanium filter instead of a copper one, reducing the tube load while maintaining image quality.

PURPOSE

To retrospectively evaluate the accuracy of contrast-enhanced mammography with a titanium filter (TiCEM) in three readers with different grades of experience.

MATERIAL AND METHODS

IRB-approved retrospective multicentric lesion by lesion study with 200 lesions, all of them initially classified as BI-RADS categories 0/3/4/5 on mammography and/or ultrasound and with pathological confirmation, in 135 patients. Three readers with different levels of experience (expert, resident, intermediate) blinded to the final diagnosis, retrospectively evaluated the low-energy (LE) images and the combination of LE and recombined (subtracted) images and classified the lesions according to the BI-RADS categories. Reader 1 also categorized the breast density. ROC curves were performed for each reader.

RESULTS

Out of the 200 lesions, 82 were benign and 118 malignant (20 DCIS, 10 ILC, 88 IDC). The AUCs of LE versus TiCEM for were: Reader 1: 0.7 vs. 0.88, P < 0.001; Reader 2: 0.63 vs. 0.83, P < 0.001; and Reader 3: 0.63 vs. 0.84, P < 0.001. For the three readers, the AUCs of LE versus TiCEM were significantly superior in both dense and non-dense breasts (P < 0.001). Comparing the AUC of LE for Reader 1 (expert) versus the AUC of TiCEM for Reader 2 (resident) there were significant differences (0.7 vs. 0.83, P < 0.001).

CONCLUSION

The accuracy of TiCEM was significantly better for all the readers, in both dense and non-dense breasts. The accuracy of a resident reading a TiCEM study was better than the accuracy of an expert radiologist reading LE images.

Contrast-enhanced mammography: past, present, and future

Contrast-enhanced mammography (CEM) combines conventional mammography with iodinated contrast material to improve cancer detection. CEM has comparable performance to breast MRI without the added cost or time of conventional MRI protocols. Thus, this technique may be useful for indications previously reserved for MRI, such as problem-solving, determining disease extent in patients with newly diagnosed cancer, monitoring response to neoadjuvant therapy, evaluating the posttreatment breast for residual or recurrent disease, and potentially screening in women at intermediate- or high-risk for breast cancer. This article will provide a comprehensive overview on the past, present, and future of CEM, including its evolving role in the diagnostic and screening settings.

A Brief Review on Breast Carcinoma and Deliberation on Current Non Invasive Imaging Techniques for Detection

BACKGROUND

Breast carcinoma is a life threatening disease that accounts for 25.1% of all carcinoma among women worldwide. Early detection of the disease enhances the chance for survival.

DISCUSSION

This paper presents comprehensive report on breast carcinoma disease and its modalities available for detection and diagnosis, as it delves into the screening and detection modalities with special focus placed on the non-invasive techniques and its recent advancement work done, as well as a proposal on a novel method for the application of early breast carcinoma detection.

CONCLUSION

This paper aims to serve as a foundation guidance for the reader to attain bird's eye understanding on breast carcinoma disease and its current non-invasive modalities.

Factors Associated With Background Parenchymal Enhancement on Contrast-Enhanced Mammography

OBJECTIVE. The purpose of this study was to determine the relationship between background parenchymal enhancement (BPE) on contrast-enhanced mammography (CEM) and breast tissue density, menstrual status, endocrine therapy, and risk factors for breast cancer and also to evaluate interreader agreement on classification of BPE on CEM. MATERIALS AND METHODS. Five subspecialty-trained breast radiologists independently and blindly graded tissue density (with fatty tissue and scattered fibroglandular tissue classified as nondense tissue and with heterogeneously dense and extremely dense classified as dense tissue) and BPE (with minimal or mild BPE categorized as low BPE and moderate or marked BPE categorized as high BPE) on CEM examinations performed from 2014 to 2018. Electronic medical charts were reviewed for information on menstrual status, endocrine therapy, history of breast surgery, and other risk factors for breast cancer. Comparisons were performed using the Kruskal-Wallis test, Mann-Whitney test, and Spearman rank correlation. Interreader agreement was estimated using the Fleiss kappa test. RESULTS. A total of 202 patients (mean [± SD] age, 54 ± 10 years; range, 25-84 years) underwent CEM. Tissue density was categorized as fatty in two patients (1%), scattered fibroglandular in 67 patients (33%), heterogeneously dense in 117 patients (58%), and extremely dense in 16 patients (8%). Among the 202 patients, BPE was minimal in 77 (38%), mild in 80 (40%), moderate in 31 (15%), and marked in 14 (7%). Dense breasts, younger age, premenopausal status, no history of endocrine therapy, and no history of breast cancer were significantly associated with high BPE. Among premenopausal patients, no association was found between BPE and time from last menstrual period to CEM. Overall interreader agreement on BPE was moderate (κ = 0.41; 95% CI, 0.40-0.42). Interreader agreement on tissue density was substantial (κ = 0.67; 95% CI, 0.66-0.69). CONCLUSION. Women with dense breasts, premenopausal status, and younger age are more likely to have greater BPE. Targeting CEM to the last menstrual period is not indicated.

Diagnostic accuracy of contrast-enhanced spectral mammography for breast lesions: A systematic review and meta-analysis

Breast cancer diagnosis and staging is based on mammography, ultrasound, and magnetic resonance imaging (MRI). Contrast enhanced spectral mammography (CESM) has gained momentum as an innovative and clinically useful method for breast assessment. CESM is based on abnormal enhancement of neoplastic tissue compared to surrounding breast tissue. We performed a systematic review of prospective trial to evaluate its diagnostic performance, following standard PRISMA-DTA. We used a bivariate random-effects regression approach to obtain summary estimates of both sensitivity and specificity of CESM. 8 studies published between 2003 and 2019 were included in the meta-analysis for a total of 945 lesions. The summary area under the curve obtained from all the study was 89% [95% CI 86%-91%], with a sensitivity of 85% [95% CI 73%-93%], and a specificity of 77% [95% CI 60%-88%]. With a pre-test probability of malignancy of 57% a positive finding at CESM gives a post-test probability of 83% while a negative finding a post-test probability of 20%. CESM shows a suboptimal sensitivity and specificity in the diagnosis of breast cancer in a selected population, and at present time, it could be considered only as a possible alternative test for breast lesions assessment when mammography and ultrasound are not conclusive or MRI is contraindicated or not available.

Nanoparticle contrast agents for X-ray imaging applications

X-ray imaging is the most widely used diagnostic imaging method in modern medicine and several advanced forms of this technology have recently emerged. Iodinated molecules and barium sulfate suspensions are clinically approved X-ray contrast agents and are widely used. However, these existing contrast agents provide limited information, are suboptimal for new X-ray imaging techniques and are developing safety concerns. Thus, over the past 15 years, there has been a rapid growth in the development of nanoparticles as X-ray contrast agents. Nanoparticles have several desirable features such as high contrast payloads, the potential for long circulation times, and tunable physicochemical properties. Nanoparticles have also been used in a range of biomedical applications such as disease treatment, targeted imaging, and cell tracking. In this review, we discuss the principles behind X-ray contrast generation and introduce new types of X-ray imaging modalities, as well as potential elements and chemical compositions that are suitable for novel contrast agent development. We focus on the progress in nanoparticle X-ray contrast agents developed to be renally clearable, long circulating, theranostic, targeted, or for cell tracking. We feature agents that are used in conjunction with the newly developed multi-energy computed tomography and mammographic imaging technologies. Finally, we offer perspectives on current limitations and emerging research topics as well as expectations for the future development of the field. This article is categorized under: Diagnostic Tools > in vivo Nanodiagnostics and Imaging Nanotechnology Approaches to Biology > Nanoscale Systems in Biology.

A review of various modalities in breast imaging: technical aspects and clinical outcomes

Background

Nowadays, breast cancer is the second cause of death after cardiovascular diseases. In general, about one out of eight women (about 12%) suffer from this disease during their life in the USA and European countries. If breast cancer is detected at an early stage, its survival rate will be very high. Several methods have been introduced to diagnose breast cancer with their clinical advantages and disadvantages.

Main text

In this review, various methods of breast imaging have been introduced. Furthermore, the sensitivity and specificity of each of these methods have been investigated. For each of the imaging methods, articles that were relevant to the past 10 years were selected through electronic search engines, and then the most relevant papers were selected. Finally, about 40 articles were studied and their results were categorized and presented in the form of a report as follows. Various breast cancer imaging techniques were extracted as follows: mammography, contrast-enhanced mammography, digital tomosynthesis, sonography, sonoelastography, magnetic resonance imaging, magnetic elastography, diffusion-weighted imaging, magnetic spectroscopy, nuclear medicine, optical imaging, and microwave imaging.

Conclusion

The choice of these methods depends on the patient’s state and stage, the age of the individual and the density of the breast tissue. Hybrid imaging techniques appear to be an acceptable way to improve detection of breast cancer. This review article can be useful in choosing the right method for imaging in people suspected of breast cancer.

Preoperative assessment of contrast-enhanced spectral mammography of diagnosed breast cancers after sonographic biopsy: Correlation to contrast-enhanced magnetic resonance imaging and 5-year postoperative follow-up

To assess the feasibility of using contrast-enhanced spectral mammography (CESM) for operative planning of patients with breast cancers who were initially diagnosed by sonographic guided biopsy.With the approval of the Institutional Review Board of our hospital, we retrospectively reviewed the data on patients with breast cancers who underwent CESM and contrast-enhanced magnetic resonance imaging (CE-MRI) prior to operation and were followed up for at least 5 years postoperatively. The patients with breast cancer diagnosed by sonographic guided biopsy without mammography were included for analysis. The size and number of cancers on low-energy mammograms (LE-MG), recombined subtracted mammograms (RSM), and CE-MRI were recorded and compared with microscopic histopathologic data and at least 5 years of clinical follow-up data.Fifty-one cancerous breasts of 46 patients were included in the analysis. All the principal cancers could be detected by RSM or CE-MRI; however, only 45 were by LE-MG. The Pearson correlation coefficients for the size on microscopy were 0.44 for LE-MG, 0.77 for RSM, and 0.84 for CE-MRI (all P-values ≤.001). Regarding the microscopic reports, RSM or CE-MRI had sensitivities of 100% and a positive predictive value of 63.6% for multicentric cancers. One breast cancer with partial mastectomy recurred after 3 years of follow-up.CESM was feasible for assessing the cancer extension and multicentric cancers as secondary examination in patients with diagnosed breast cancers after sonographic biopsy.

Digital breast tomosynthesis and contrast-enhanced dual-energy digital mammography alone and in combination compared to 2D digital synthetized mammography and MR imaging in breast cancer detection and classification

To compare diagnostic performance of contrast-enhanced dual-energy digital mammography (CEDM) and digital breast tomosynthesis (DBT) alone and in combination compared to 2D digital mammography (MX) and dynamic contrast-enhanced MRI (DCE-MRI) in women with breast lesions. We enrolled 100 consecutive patients with breast lesions (BIRADS 3-5 at imaging or clinically suspicious). CEDM, DBT, and DCE-MRI 2D were acquired. Synthetized MX was obtained by DBT. A total of 134 lesions were investigated on 111 breasts of 100 enrolled patients: 53 were histopathologically proven as benign and 81 as malignant. Nonparametric statistics and receiver operating characteristic (ROC) curve were performed. Two-dimensional synthetized MX showed an area under ROC curve (AUC) of 0.764 (sensitivity 65%, specificity 80%), while AUC was of 0.845 (sensitivity 80%, specificity 82%) for DBT, of 0.879 (sensitivity 82%, specificity 80%) for CEDM, and of 0.892 (sensitivity 91%, specificity 84%) for CE-MRI. DCE-MRI determined an AUC of 0.934 (sensitivity 96%, specificity 88%). Combined CEDM with DBT findings, we obtained an AUC of 0.890 (sensitivity 89%, specificity 74%). A difference statistically significant was observed only between DCE-MRI and CEDM (P = .03). DBT, CEDM, CEDM combined to tomosynthesis, and DCE-MRI had a high ability to identify multifocal and bilateral lesions with a detection rate of 77%, 85%, 91%, and 95% respectively, while 2D synthetized MX had a detection rate for multifocal lesions of 56%. DBT and CEDM have superior diagnostic accuracy of 2D synthetized MX to identify and classify breast lesions, and CEDM combined with DBT has better diagnostic performance compared with DBT alone. The best results in terms of diagnostic performance were obtained by DCE-MRI. Dynamic information obtained by time-intensity curve including entire phase of contrast agent uptake allows a better detection and classification of breast lesions.

BIRADS 4 breast lesions: comparison of contrast-enhanced spectral mammography and contrast-enhanced MRI

Background

Breast cancer is the most common cancer in women worldwide. It is responsible for about 23% of cancer in females in both developed and developing countries [1]. We aimed to assess the accuracy of contrast-enhanced spectral mammography (CESM) versus contrast-enhanced breast MRI in the evaluation of BIRADS 4 breast lesions.

Results

Fifty patients were included in this study; there were 28 malignant cases and 22 benign cases; all cases were proved by histopathological result either by core biopsy or excision biopsy. CESM was found to have less sensitivity (94.1%) than MRI (100%) but CESM has higher specificity (100%) than MRI (95.5%). The accuracy of CESM was 96.4%, while the accuracy of MRI was 98.2% with no statistical significance (P value 0.827).

Conclusion

CESM can be used as a sensitive diagnostic tool in the detection and staging of breast cancer with higher specificity and less sensitivity as compared to contrast enhanced breast MRI.

Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review

We reviewed technical parameters, acquisition protocols and adverse reactions (ARs) for contrast-enhanced spectral mammography (CESM). A systematic search in databases, including MEDLINE/EMBASE, was performed to extract publication year, country of origin, study design; patients; mammography unit/vendor, radiation dose, low-/high-energy tube voltage; contrast molecule, concentration and dose; injection modality, ARs and acquisition delay; order of views; examination time. Of 120 retrieved articles, 84 were included from 22 countries (September 2003-January 2019), totalling 14012 patients. Design was prospective in 44/84 studies (52%); in 70/84 articles (83%), a General Electric unit with factory-set kVp was used. Per-view average glandular dose, reported in 12/84 studies (14%), ranged 0.43-2.65 mGy. Contrast type/concentration was reported in 79/84 studies (94%), with Iohexol 350 mgI/mL mostly used (25/79, 32%), dose and flow rate in 72/84 (86%), with 1.5 mL/kg dose at 3 mL/s in 62/72 studies (86%). Injection was described in 69/84 articles (82%), automated in 59/69 (85%), manual in 10/69 (15%) and flush in 35/84 (42%), with 10-30 mL dose in 19/35 (54%). An examination time < 10 min was reported in 65/84 studies (77%), 120 s acquisition delay in 65/84 (77%) and order of views in 42/84 (50%) studies, beginning with the craniocaudal view of the non-suspected breast in 7/42 (17%). Thirty ARs were reported by 14/84 (17%) studies (26 mild, 3 moderate, 1 severe non-fatal) with a pooled rate of 0.82% (fixed-effect model). Only half of CESM studies were prospective; factory-set kVp, contrast 1.5 mL/kg at 3 mL/s and 120 s acquisition delay were mostly used; only 1 severe AR was reported. CESM protocol standardisation is advisable.

Correlation between quantitative assessment of contrast enhancement in contrast-enhanced spectral mammography (CESM) and histopathology-preliminary results

Objectives

Contrast-enhanced spectral mammography (CESM) is a novel method for breast cancer detection. The aim of this study is to check if there is a possibility of quantitative assessment of contrast enhancement in CESM and if there is any correlation between quantitative assessment of contrast enhancement in CESM and histopathology.

Methods

A total of 167 female patients underwent CESM. All subjects previously had suspicious lesions found on mammography, breast ultrasound, or both. After imaging, the following parameters were evaluated: number of enhancing lesions in each breast and size and degree of enhancement of each lesion. Based on the collected data, the percentage signal difference between enhancing lesion and background (%RS) and signal-difference-to-noise ratio (SDNR) were measured for each lesion.

Results

The number of lesions detected in the study population was 195. Among all diagnosed lesions, 120 (62%) were assessed to be infiltrating cancers, 16 (8%) non-infiltrating cancers, and 59 (30%) were benign. Thirteen (7%) lesions did not enhance in CESM; all non-enhancing lesions were confirmed to be benign under histopathological examination. Analysis of enhancement indices showed that signal values within lesions and signal values within background ROIs (regions of interest) were similar in CC (craniocaudal) and MLO (mediolateral) projections. Mean %RS values were correlated with the type of enhancing lesion, infiltrating cancers having the highest values, benign lesions the lowest.

Conclusions

This work has demonstrated a significant correlation between the degree of lesion enhancement in CESM and malignancy. Quantitative analysis of enhancement levels in CESM can distinguish between invasive cancers and benign or in situ lesions.

Key Points

• There is a possibility of quantitative assessment of contrast enhancement in CESM.

• Correlation between quantitative assessment of contrast enhancement in CESM and histopathology was observed.

Angiomammography: A review of current evidences

Although mammography is currently the imaging technique of choice for screening and diagnosis, it has some limitations, especially in patients with high-density breasts. The evolution from film screen to full-field digital mammography has recently led to the development of new imaging techniques, which are less expensive and widely available. Contrast-enhanced spectral mammography (CESM) is one of them, coupling X-ray breast imaging to the intravenous administration of an iodinated contrast material. CESM provides both morphological information, similar to mammography, and functional information of tumor perfusion. In this review, the imaging technique, the specificity of interpretation of CESM compared to MRI and the currently available data are presented. The clinical performances of CESM versus those of mammography and MRI and its additional value in preoperative local assessment and screening is discussed. The potential advantages and disadvantages are mentioned and we also discuss how CESM contributes to the detection of lesions and how it can be used in daily clinical workflow.

Comparison of contrast-enhanced digital mammography and contrast-enhanced digital breast tomosynthesis for lesion assessment

Contrast-enhanced digital mammography (CEDM) reveals neovasculature of breast lesions in a two-dimensional contrast enhancement map. Contrast-enhanced digital breast tomosynthesis (CEDBT) provides contrast enhancement in three dimensions, which may improve lesion characterization and localization. We aim to compare CEDM and CEDBT for lesion assessment. Women with breast imaging-reporting and data system 4 or 5 suspicious breast lesion(s) were recruited in our study and were imaged with CEDM and CEDBT in succession under one breast compression. Two radiologists assessed CEDM and CEDBT with both images displayed side-by-side and compared (1) contrast enhancement of lesions and (2) lesion margin using a five-point scale ranging from - 2 (CEDM much better) to + 2 (CEDBT much better). Biopsy identified 19 malignant lesions with contrast enhancement. Our results show that CEDBT provides better lesion margins than CEDM with limited reduction in contrast enhancement. CEDBT delivers less radiation dose compared to CEDM + DBT. Synthetic CEDM can be generated from CEDBT data and provides lesion contrast enhancement comparable to CEDM. CEDBT has potential for clinical applications, such as treatment response monitoring and guidance for biopsy.

Diagnostic Value of Contrast-Enhanced Digital Mammography versus Contrast-Enhanced Magnetic Resonance Imaging for the Preoperative Evaluation of Breast Cancer

Purpose

This study aimed to compare the diagnostic performance of contrast-enhanced digital mammography (CEDM) and contrast-enhanced magnetic resonance imaging (CEMRI) in preoperative evaluations, and to evaluate the effect of each modality on the surgical management of women with breast cancer.

Methods

This single-center, prospective study was approved by the Institutional Review Board, and informed consent was obtained from all patients. From November 2016 to October 2017, 84 patients who were diagnosed with invasive carcinoma (69/84) and ductal carcinoma in situ (15/84), and underwent both CEDM and CEMRI, were enrolled. Imaging findings and surgical management were correlated with pathological results and compared. The diagnostic performance of both modalities in the detection of index and secondary cancers (multifocality and multicentricity), and occult cancer in the contralateral breast, was compared. The authors also evaluated whether CEDM or CEMRI resulted in changes in the surgical management of the affected breast due to imaging-detected findings.

Results

Eighty-four women were included in the analysis. Compared with CEMRI, CEDM demonstrated a similar sensitivity (92.9% [78/84] vs. 95.2% [80/84]) in detecting index cancer (p=0.563). For the detection of secondary cancers in the ipsilateral breast and occult cancer in the contralateral breast, no significant differences were found between CEDM and CEMRI (p=0.999 and p=0.999, respectively). Regarding changes in surgical management, CEDM resulted in similar changes compared with CEMRI (30.9% [26/84] vs. 29.7% [25/84], p=0.610). Regarding changes in surgical management due to false-positive findings, no significant differences were found between CEDM and CEMRI (34.6% [9/26] vs. 44.0% [11/25], p=0.782).

Conclusion

CEDM demonstrated a diagnostic performance comparable with CEMRI in depicting index cancers, secondary cancers, and occult cancer in the contralateral breast. CEDM demonstrated similar changes in surgical management compared with CEMRI.

Combined Benefit of Quantitative Three-Compartment Breast Image Analysis and Mammography Radiomics in the Classification of Breast Masses in a Clinical Data Set

Purpose To investigate the combination of mammography radiomics and quantitative three-compartment breast (3CB) image analysis of dual-energy mammography to limit unnecessary benign breast biopsies. Materials and Methods For this prospective study, dual-energy craniocaudal and mediolateral oblique mammograms were obtained immediately before biopsy in 109 women (mean age, 51 years; range, 31-85 years) with Breast Imaging Reporting and Data System category 4 or 5 breast masses (35 invasive cancers, 74 benign) from 2013 through 2017. The three quantitative compartments of water, lipid, and protein thickness at each pixel were calculated from the attenuation at high and low energy by using a within-image phantom. Masses were automatically segmented and features were extracted from the low-energy mammograms and the quantitative compartment images. Tenfold cross-validations using a linear discriminant classifier with predefined feature signatures helped differentiate between malignant and benign masses by means of (a) water-lipid-protein composition images alone, (b) mammography radiomics alone, and (c) a combined image analysis of both. Positive predictive value of biopsy performed (PPV₃) at maximum sensitivity was the primary performance metric, and results were compared with those for conventional diagnostic digital mammography. Results The PPV₃ for conventional diagnostic digital mammography in our data set was 32.1% (35 of 109; 95% confidence interval [CI]: 23.9%, 41.3%), with a sensitivity of 100%. In comparison, combined mammography radiomics plus quantitative 3CB image analysis had PPV₃ of 49% (34 of 70; 95% CI: 36.5%, 58.9%; P < .001), with a sensitivity of 97% (34 of 35; 95% CI: 90.3%, 100%; P < .001) and 35.8% (39 of 109) fewer total biopsies (P < .001). Conclusion Quantitative three-compartment breast image analysis of breast masses combined with mammography radiomics has the potential to reduce unnecessary breast biopsies. © RSNA, 2018 Online supplemental material is available for this article.

Utility of routine use of breast ultrasound following contrast-enhanced spectral mammography

AIM

To evaluate whether breast ultrasound (US) is routinely indicated following contrast-enhanced spectral mammography (CESM).

MATERIALS AND METHODS

Consecutive screening and diagnostic CESM examinations with concurrent breast US were collected retrospectively (May 2012 to February 2016). Radiologists assigned a separate Breast Imaging-Reporting and Data System (BIRADS) score for CESM and for US. BIRADS scores were grouped into three categories: normal/benign appearing (BIRADS 1, 2); probably benign, short-term follow-up (BIRADS 3); or suspicious appearing (BIRADS 0, 4, 5). Patients with a suspicious-appearing lesion in either US or CESM underwent biopsy. The associations between malignant pathology with either suspicious-appearing CESM or suspicious-appearing US were calculated. The sensitivities and specificities of CESM and US were analysed.

RESULTS

Eighty-seven lesions were biopsied, 37 (43%) biopsies were malignant and 50 (57%) were benign. Although suspicious-appearing CESM was associated with malignant biopsies (p<0.0001), suspicious-appearing US was not (p=0.985). Among 37 malignant biopsies, CESM had a sensitivity of 97% (36/37 lesions), compared to 92% (34/37 lesions) with US. None of the malignant biopsies were normal/benign appearing with CESM. One case of follow-up CESM was suspicious-appearing at US and proved to be malignant on biopsy. The specificity of CESM was 40%, which was significantly higher than US at 8%.

CONCLUSION

When CESM is suspicious appearing, subsequent US and biopsy is appropriate. With a CESM BIRADS 3, correlation with US is suggested. If the CESM is benign appearing, the routine use of US is questionable, as it may lead to unnecessary benign biopsies.

Personalised screening: is this the way forward?

Screening with mammography has been implemented in many countries across the world with most offering 2-yearly examinations between the ages of 50-69 years. Robust modelling tools that include breast density and single nucleotide polymorphisms (SNPs) have been developed to predict which women are most likely to develop breast cancer. Mammographic sensitivity is poor in women with the densest category of breast tissue, and even women with heterogeneously dense tissue may benefit from additional supplemental imaging. Digital breast tomosynthesis (DBT), automated breast ultrasound (ABUS), contrast-enhanced mammography (CESM) or abbreviated (ABB) magnetic resonance imaging (MRI) all offer the opportunity to increase cancer detection, especially in women with dense breasts at increased risk of cancer. DBT increases cancer detection by around 15% with a corresponding reduction in recall rates; ABUS has been shown to increase cancer detection by between 2-4/1,000 depending on the cohort being examined and results in increased recalls, which tend to fall in subsequent screening rounds; CESM has very high sensitivity almost matching MRI with slightly improved specificity; ABB-MRI has been shown to be virtually equivalent to standard protocol MRI examinations, making this a technique that could be considered as a screening tool in high-risk women. This article reviews the literature to establish the current status of these techniques. The cost-effectiveness of these techniques requires further investigation and screening trials should report the nature of any additional tumours that are found.

Contrast-enhanced spectral mammography in neoadjuvant chemotherapy monitoring: a comparison with breast magnetic resonance imaging

BACKGROUND

Neoadjuvant-chemotherapy (NAC) is considered the standard treatment for locally advanced breast carcinomas. Accurate assessment of disease response is fundamental to increase the chances of successful breast-conserving surgery and to avoid local recurrence. The purpose of this study was to compare contrast-enhanced spectral mammography (CESM) and contrast-enhanced-MRI (MRI) in the evaluation of tumor response to NAC.

METHODS

This prospective study was approved by the institutional review board and written informed consent was obtained. Fifty-four consenting women with breast cancer and indication of NAC were consecutively enrolled between October 2012 and December 2014. Patients underwent both CESM and MRI before, during and after NAC. MRI was performed first, followed by CESM within 3 days. Response to therapy was evaluated for each patient, comparing the size of the residual lesion measured on CESM and MRI performed after NAC to the pathological response on surgical specimens (gold standard), independently of and blinded to the results of the other test. The agreement between measurements was evaluated using Lin's coefficient. The agreement between measurements using CESM and MRI was tested at each step of the study, before, during and after NAC. And last of all, the variation in the largest dimension of the tumor on CESM and MRI was assessed according to the parameters set in RECIST 1.1 criteria, focusing on pathological complete response (pCR).

RESULTS

A total of 46 patients (85%) completed the study. CESM predicted pCR better than MRI (Lin's coefficient 0.81 and 0.59, respectively). Both methods tend to underestimate the real extent of residual tumor (mean 4.1mm in CESM, 7.5mm in MRI). The agreement between measurements using CESM and MRI was 0.96, 0.94 and 0.76 before, during and after NAC respectively. The distinction between responders and non-responders with CESM and MRI was identical for 45/46 patients. In the assessment of CR, sensitivity and specificity were 100% and 84%, respectively, for CESM, and 87% and 60% for MRI.

CONCLUSION

CESM and MRI lesion size measurements were highly correlated. CESM seems at least as reliable as MRI in assessing the response to NAC, and may be an alternative if MRI is contraindicated or its availability is limited.

Application of BI-RADS Descriptors in Contrast-Enhanced Dual-Energy Mammography: Comparison with MRI

BACKGROUND

Contrast-enhanced (CE) magnetic resonance imaging (MRI) BI-RADS descriptors are used in the evaluation of contrast-enhanced dual-energy mammography (CEDEM) images of mass lesions and are assumed to be applicable.

PATIENTS AND METHODS

Patients with suspicious mass lesions on mammography (BI-RADS 4 or 5) were included. CEDEM examinations were performed using a modified prototype unit. CE-MRI was performed using a high temporal and high spatial resolution imaging protocol. 2 blinded breast radiologists evaluated all images using criteria related to contrast enhancement intensity and morphology according to the BI-RADS lexicon (5th edition) in 2 sessions. Histopathology was used as the standard of reference.

RESULTS

11 patients with 5 benign and 6 malignant index lesions were included. Enhancement characteristics were similar in the malignant cases. Enhancement of the benign lesions was moderate on CEDEM and strong on MRI. Discrepancies in the BI-RADS descriptors did not influence the final BI-RADS score. Overall, the BI-RADS assessment was almost identical in all cases. 1 malignant lesion was rated BI-RADS 4 with CEDEM and BI-RADS 5 with MRI, and 1 benign was rated BI-RADS 2 and BI-RADS 1, respectively.

CONCLUSION

MRI BI-RADS descriptors of contrast-enhancing lesions can be applied for the morphologic analysis of mass lesions on CEDEM.

False-negative contrast-enhanced spectral mammography: use of more than one imaging modality and application of the triple test avoids misdiagnosis

A 50-year-old woman presented with chest tenderness. On examination, both breasts were lumpy. Bilateral mammography showed heterogeneously dense parenchyma, with possible stromal distortion laterally on the right at the 0900 position. On ultrasound (US), a corresponding 13×9×10 mm irregular hypoechoic mass with internal vascularity was noted and both breasts had a complex heterogeneous fibroglandular background pattern. US-guided core biopsy with marker clip insertion was performed with the diagnosis of a grade 2 invasive ductal carcinoma (IDC). In view of the parenchymal pattern on mammography and US, contrast-enhanced spectral mammography (CESM) was performed for local staging. Mild background enhancement was noted, but there was no enhancement at the lesion site. The patient elected to have bilateral mastectomies and sentinel node biopsies. Final histopathology showed a node negative 11 mm grade 2 oestrogen and progesterone receptor positive, IDC.

Optimization of contrast-enhanced breast imaging: Analysis using a cascaded linear system model

PURPOSE

Contrast-enhanced (CE) breast imaging involves the injection contrast agents (i.e., iodine) to increase conspicuity of malignant lesions. CE imaging may be used in conjunction with digital mammography (DM) or digital breast tomosynthesis (DBT) and has shown promise in improving diagnostic specificity. Both CE-DM and CE-DBT techniques require optimization as clinical diagnostic tools. Physical factors including x-ray spectra, subtraction technique, and the signal from iodine contrast, must be considered to provide the greatest object detectability and image quality. We developed a cascaded linear system model (CLSM) for the optimization of CE-DM and CE-DBT employing dual energy (DE) subtraction or temporal (TE) subtraction.

METHODS

We have previously developed a CLSM for DBT implemented with an a-Se flat panel imager (FPI) and filtered backprojection (FBP) reconstruction algorithm. The model is used to track image quality metrics - modulation transfer function (MTF) and noise power spectrum (NPS) - at each stage of the imaging chain. In this study, the CLSM is extended for CE breast imaging. The effect of x-ray spectrum (varied by changing tube potential and the filter) and DE and TE subtraction techniques on breast structural noise was measured was studied and included as a deterministic source of noise in the CLSM. From the two-dimensional (2D) and three-dimensional (3D) MTF and NPS, the ideal observer signal-to-noise ratio (SNR), also known as the detectability index (d'), may be calculated. Using d' as a FOM, we discuss the optimization of CE imaging for the task of iodinated contrast object detection within structured backgrounds.

RESULTS

Increasing x-ray energy was determined to decrease the magnitude of structural noise and not its correlation. By performing DE subtraction, the magnitude of the structural noise was further reduced at the expense of increased stochastic (quantum and electronic) noise. TE subtraction exhibited essentially no residual structural noise at the expense of increased quantum noise, even over that of the DE case. For DE subtraction, optimization of dose weighting to the HE view (f_h ) results in the minimization of quantum noise. Both subtraction weighting factor (w_Sub ) and the iodine contrast signal were dependent on the LE and HE x-ray spectra. To best detect a 5 mm Gaussian lesion with 5 mg/ml of iodine within a 4 cm thick breast, it was found that the high energy (HE) view should be acquired with a tube potential of 47 kVp (W/Ti spectrum) and the low energy (LE) view with a potential of 23 kVp (W/Rh spectrum). Due to the complete removal of structural noise, TE subtraction produced much higher d' than DE subtraction both as a function of mean glandular dose and iodine concentration.

CONCLUSIONS

We have shown the effect of increasing x-ray energy as well as projection domain subtraction on breast structural noise. Further, we have exhibited the utility of the CLSM for DE and TE subtraction CE imaging in the optimization of imaging parameters such as x-ray energy, f_h , and w_Sub as well as guiding the understanding of their effects on image contrast and noise.

Degree of Enhancement on Contrast Enhanced Spectral Mammography (CESM) and Lesion Type on Mammography (MG): Comparison Based on Histological Results

Background

Contrast enhanced spectral mammography (CESM) is a new method of breast cancer diagnosis in which an iodinated contrast agent is injected and dual-energy mammography is obtained in multiple views of the breasts. The aim of this study was to compare the degree of enhancement on CESM with lesion characteristics on mammography (MG) and lesion histology in women with suspicious breast lesions.

Material/Methods

The degree of enhancement on CESM (absent, weak, medium, or strong) was compared to lesion characteristics on MG (mass, mass with microcalcifications, or microcalcifications alone) and histology (infiltrating carcinoma, intraductal carcinoma, or benign) to compare sensitivity of the two modalities and to establish correlations that might improve diagnostic accuracy.

Results

Among 225 lesions identified with CESM and MG, histological evaluation revealed 143 carcinomas (127 infiltrating, 16 intraductal) and 82 benign lesions. This is the largest cohort investigated with CESM to date. The sensitivity of CESM was higher than that of MG (100% and 90%, respectively, p=0.010). Medium or strong enhancement on CESM and the presence of a mass on MG was the most likely indictor of malignancy (55.1% p=0.002). Among benign lesions, 60% presented as enhancement on CESM (were false-positive), and most frequently as medium or weak enhancement, together with a mass on MG (53%, p=0.047). Unfortunately, the study did not find combinations of MG findings and CESM enhancement patterns that would be helpful in defining false-positive lesions. We observed systematic overestimation of maximum lesion diameter on CESM compared to histology (mean difference: 2.29 mm).

Conclusions

Strong or medium enhancement on CESM and mass or mass with microcalcifications on MG were strong indicators of malignant transformation. However, we found no combination of MG and CESM characteristics helpful in defining false-positive lesions.

Clinical study of contrast-enhanced digital mammography and the evaluation of blood and lymphatic microvessel density

OBJECTIVE

To correlate image parameters in contrast-enhanced digital mammography (CEDM) with blood and lymphatic microvessel density (MVD).

METHODS

18 Breast Imaging-Reporting and Data System (BI-RADS)-4 to BI-RADS-5 patients were subjected to CEDM. Craniocaudal views were acquired, two views (low and high energy) before iodine contrast medium (CM) injection and four views (high energy) 1-5 min afterwards. Processing included registration and two subtraction modalities, traditional single-energy temporal (high-energy) and "dual-energy temporal with a matrix", proposed to improve lesion conspicuity. Images were calibrated into iodine thickness, and iodine uptake, contrast, time-intensity and time-contrast kinetic curves were quantified. Image indicators were compared with MVD evaluated by anti-CD105 and anti-podoplanin (D2-40) immunohistochemistry.

RESULTS

11 lesions were cancerous and 7 were benign. CEDM subtraction strongly increased conspicuity of lesions enhanced by iodine uptake. A strong correlation was observed between lymphatic vessels and blood vessels; all benign lesions had <30 blood microvessels per field, and all cancers had more than this value. MVD showed no correlation with iodine uptake, nor with contrast. The most frequent curve was early uptake followed by plateau for uptake and contrast in benign and malignant lesions. The positive-predictive value of uptake dynamics was 73% and that of contrast was 64%.

CONCLUSION

CEDM increased lesion visibility and showed additional features compared with conventional mammography. Lack of correlation between image parameters and MVD is probably due to tumour tissue heterogeneity, mammography projective nature and/or dependence of extracellular iodine irrigation on tissue composition.

ADVANCES IN KNOWLEDGE

Quantitative analysis of CEDM images was performed. Image parameters and MVD showed no correlation. Probably, this is indication of the complex dependence of CM perfusion on tumour microenvironment.

Comparison of Background Parenchymal Enhancement at Contrast-enhanced Spectral Mammography and Breast MR Imaging

Purpose To assess the extent of background parenchymal enhancement (BPE) at contrast material-enhanced (CE) spectral mammography and breast magnetic resonance (MR) imaging, to evaluate interreader agreement in BPE assessment, and to examine the relationships between clinical factors and BPE. Materials and Methods This was a retrospective, institutional review board-approved, HIPAA-compliant study. Two hundred seventy-eight women from 25 to 76 years of age with increased breast cancer risk who underwent CE spectral mammography and MR imaging for screening or staging from 2010 through 2014 were included. Three readers independently rated BPE on CE spectral mammographic and MR images with the ordinal scale: minimal, mild, moderate, or marked. To assess pairwise agreement between BPE levels on CE spectral mammographic and MR images and among readers, weighted κ coefficients with quadratic weights were calculated. For overall agreement, mean κ values and bootstrapped 95% confidence intervals were calculated. The univariate and multivariate associations between BPE and clinical factors were examined by using generalized estimating equations separately for CE spectral mammography and MR imaging. Results Most women had minimal or mild BPE at both CE spectral mammography (68%-76%) and MR imaging (69%-76%). Between CE spectral mammography and MR imaging, the intrareader agreement ranged from moderate to substantial (κ = 0.55-0.67). Overall agreement on BPE levels between CE spectral mammography and MR imaging and among readers was substantial (κ = 0.66; 95% confidence interval: 0.61, 0.70). With both modalities, BPE demonstrated significant association with menopausal status, prior breast radiation therapy, hormonal treatment, breast density on CE spectral mammographic images, and amount of fibroglandular tissue on MR images (P < .001 for all). Conclusion There was substantial agreement between readers for BPE detected on CE spectral mammographic and MR images. ^© RSNA, 2016.

Preclinical study of diagnostic performances of contrast-enhanced spectral mammography versus MRI for breast diseases in China

Purpose

To evaluate diagnostic performances of CESM for breast diseases with comparison to breast MRI in China.

Materials and methods

Sixty-eight patients with 77 breast lesions underwent MR and CESM. Two radiologists interpreted either MRI or CESM images, separately and independently. BI-RADS 1–3 and BI-RADS 4–5 were classified into the suspicious benign and suspicious malignant groups. Diagnostic accuracy parameters were calculated. Receiver operating characteristic (ROC) curves were constructed for the two modalities. The agreement and correlation between maximum lesion diameter based on CESM and MRI, or CESM and pathology were analyzed.

Results

Diagnostic accuracy parameters for CESM were sensitivity 95.8 %, specificity 65.5 %, PPV 82.1 %, NPV 90.5 % and accuracy 84.4 %. The diagnostic accuracy parameters for breast MRI were sensitivity 93.8 %, specificity 82.8 %, PPV 88.2 %, NPV 92.3 %and accuracy 89.6 %. Area under the curve (AUC) of ROC was 0.96 for breast MRI and 0.88 for CESM. The Bland–Altman plots showed a mean difference of 0.7 mm with 95 % limits of agreement of 11.4 mm in tumor diameter measured using CESM and breast MRI. The differences of size measurement between CESM and breast MRI were significant, whereas no difference was observed between CESM and pathology as well as between breast MRI and pathology. The better correlation with pathological results was found in CESM than breast MRI.

Conclusion

Our study demonstrates that CESM possesses better diagnostic performances than breast MRI in terms of diagnostic sensitivity and lesion size assessment. And CESM is a good alternative method of screening breast cancer in high-risk people.

Clinical evaluation of contrast-enhanced digital mammography and contrast enhanced tomosynthesis--Comparison to contrast-enhanced breast MRI

PURPOSE

To compare the diagnostic accuracy of contrast-enhanced digital mammography (CEDM) and contrast-enhanced tomosynthesis (CET) to dynamic contrast enhanced breast MRI (DCE-MRI) using a multireader-multicase study.

METHODS

Institutional review board approval and informed consents were obtained. Total 185 patients (mean age 51.3) with BI-RADS 4 or 5 lesions were evaluated before biopsy with mammography, tomosynthesis, CEDM, CET and DCE-MRI. Mediolateral-oblique and cranio-caudal views of the target breast CEDM and CET were acquired at 2 and 4 min after contrast agent injection. A mediolateral-oblique view of the non-target breast was taken at 6 min. Each lesion was scored with forced BI-RADS categories by three readers. Each reader interpreted lesions in the following order: mammography, tomosynthesis, CEDM, CET, and DCE-MRI during a single reading session.

RESULTS

Histology showed 81 cancers and 144 benign lesions in the study. Of the 81 malignant lesions, 44% (36/81) were invasive and 56% (45/81) were non-invasive. Areas under the ROC curve, averaged for the 3 readers, were as follows: 0.897 for DCE-MRI, 0.892 for CET, 0.878 for CEDM, 0.784 for tomosynthesis and 0.740 for mammography. Significant differences in AUC were found between the group of contrast enhanced modalities (CEDM, CET, DCE-MRI) and the unenhanced modalities (all p<0.05). No significant differences were found in AUC between DCE-MRI, CET and CEDM (all p>0.05).

CONCLUSION

CET and CEDM may be considered as an alternative modality to MRI for following up women with abnormal mammography. All three contrast modalities were superior in accuracy to conventional digital mammography with or without tomosynthesis.