Preoperative staging by multimodal imaging in newly diagnosed breast cancer: Diagnostic performance of contrast-enhanced spectral mammography compared to conventional mammography, ultrasound, and MRI

Factors Influencing Background Parenchymal Enhancement in Breast Contrast-Enhanced Mammography: A Retrospective Study

Objective

To evaluate the association between background parenchymal enhancement (BPE) level and extent on contrast-enhanced mammography (CEM) with age, menopausal status, breast density, and menstrual cycle phase in women. Additionally, to characterize the dynamic changes in BPE during CEM.

Methods

This retrospective study included 103 women who underwent CEM at a single institution between September 2019 and November 2021 for screening or diagnostic purposes. Menopausal status and menstrual cycle phase were recorded for all patients. BPE on subtracted CEM images was assessed quantitatively (region of interest [ROI] analysis of pixel values) and qualitatively (subjective classification). Statistical analysis was performed to determine the relationship between BPE (level and extent) and age, menopausal status, breast density, and menstrual cycle phase. Dynamic changes in BPE level over time were also analyzed.

Results

Both BPE level and extent were negatively correlated with age (P=0.004, r=-0.280; P=0.001, r=-0.318). Postmenopausal women exhibited lower BPE level and extent compared to premenopausal women (P=0.003, Z=-2.958; P=0.042, 2=4.123). No significant association was observed between BPE and breast density or menstrual cycle phase (P>0.05). BPE level increased significantly from 3 to 9 minutes post-contrast injection (P<0.001, t=-10.7).

Conclusion

BPE in CEM is significantly associated with age and menopausal status. Further research is needed to clarify the relationship between BPE and breast density and menstrual cycle phase. BPE demonstrates a dynamic increase in level over time, this relates to post-contrast injection, rather than to the age of the woman.

Non-enhancing asymmetries on screening contrast-enhanced mammography: Is further diagnostic workup required?

OBJECTIVES

Asymmetries on screening contrast-enhanced mammography (CEM) often lead to patient recall. However, in diagnostic settings, negative CEM has effectively classified these as normal or benign, questioning the need for further workup of non-enhancing asymmetries (NEAs).

MATERIAL AND METHODS

A computational search of all screening CEM examinations performed between December-2012 and June-2021 was conducted to identify cases reporting NEAs. Their diagnostic workup was reviewed, and the positive predictive value for cancer was statistically compared to that of enhancing asymmetries on screening CEMs.

RESULTS

During the study period, 97 cases of 106 NEAs were identified among 3,482 screening CEM exams (2.8 %). NEAs were classified as asymmetry (n = 83), focal asymmetry (n = 22), and global asymmetry (n = 1), with no cases of developing asymmetry. The mean size of NEAs was 1.0 ± 0.7 cm (range: 0.3-4.9 cm). Diagnostic workup for NEAs included additional mammographic views (AMV) (n = 63), AMV plus ultrasound (n = 30), AMV plus MRI (n = 1), and all three modalities (n = 3), leading to four biopsies. None of the NEAs were malignant on follow-up, as opposed to enhancing asymmetries (P < 0.05).

CONCLUSION

NEAs detected on CEM were relatively uncommon and were usually investigated with additional mammographic views and US, yielding no cancer. Ruling out malignancy based on lack of enhancement without further workup may reduce patient recall rates and improve CEMs specificity.

Breast non-mass enhancement lesions on contrast-enhanced mammography: modified breast image reporting and data system classification

AIM

To investigate the utility of contrast-enhanced mammography (CEM) in the differential diagnosis of breast non-mass enhancement (NME) lesions, and to compare the diagnostic performance of BI-RADS for NME lesions in MG, US, MRI, and CEM.

MATERIALS AND METHODS

A total of 120 patients were included from April 2019 to April 2022. The independent enhancement descriptors for malignancy of NME were identified through binary logistic regression analysis. The modified BI-RADS in CEM (mBI-RADS (CEM)) was defined after adjusting the BI-RADS (MG) by independent descriptors. The diagnostic performances of BI-RADS in low-energy image, US, MRI, and CEM were evaluated and compared using receiver operating characteristic (ROC) analysis and DeLong's test.

RESULTS

The enhancement descriptors of enhancement morphological distribution, internal enhancement pattern and time-signal intensity curve were identified as independent risk factors for malignancy (all P≤0.001). For all-group NME analyses, the areas under the curve (AUCs) of mBI-RADS (CEM) were higher than those of BI-RADS (MG) (all P<0.050). For sub-group NME analyses, the AUCs of mBI-RADS (CEM) and BI-RADS (MRI) were higher than those of BI-RADS (MG) and BI-RADS (US) (all P<0.001). While in NME with non-micro-calcification sub-group, the area under the receiver operating characteristics curve of mBI-RADS (CEM) was higher than those of BI-RADS (MRI), both of which were higher than those of BI-RADS (MG) and BI-RADS (US) (all P<0.050).

CONCLUSION

The mBI-RADS (CEM), which integrates morphological and enhancement features, can significantly improve the diagnostic accuracy compared with BI-RADS (MG). Furthermore, the mBI-RADS (CEM) demonstrated specific advantages for NME with micro-calcifications compared with BI-RADS (MRI).

Contrast-Enhanced Mammography: A Literature Review of Clinical Uses for Cancer Diagnosis and Surgical Oncology

Contrast-enhanced mammography (CEM) uses intermittent dual-energy (low- and high-energy) exposures to produce low-energy mammograms and recombine enhanced images after the administration of iodized contrast medium, which provides more detailed information to detect breast cancers by using the features of morphology and abnormal uptake. In this article, we reviewed the literature to clarify the clinical applications of CEM, including (1) the fundamentals of CEM: the technique, radiation exposure, and image interpretation; (2) its clinical uses for cancer diagnosis, including problem-solving, palpable mass, suspicious microcalcification, architecture distortion, screening, and CEM-guided biopsy; and (3) the concerns of surgical oncology in pre-operative and neoadjuvant chemotherapy assessments. CEM undoubtedly plays an important role in clinical practice.

Defining Breast Cryoablation Treatment Success: A Guide for the Curative and Palliative Treatment of Breast Cancer

RATIONALE AND OBJECTIVES

Recent ICE3 trial of breast cryoablation for breast cancer demonstrated 98% success rate, similar to breast-conserving surgery. However, ICE3 and other published studies did not differentiate curative from palliative treatment nor define patient-specific treatment objectives. We sought to define treatment success of curative and palliative breast cryoablation for breast cancer in meeting procedure objectives and patient-specific treatment objectives.

MATERIALS AND METHODS

We conducted a retrospective analysis of breast cancer patients who underwent breast cryoablation during 2021-2024. Breast radiologists performed outpatient cryoablation using local anesthesia and argon gas cryoprobes under ultrasound or MRI guidance. Patient demographics, referral indications, tumor characteristics, procedure details, and imaging follow-up findings were analyzed. Cryoablation was categorized as curative or palliative. Treatment success was defined as achievement of both procedure and patient-specific treatment objectives.

RESULTS

Breast cryoablation was performed for 34 lesions in 29 patients with N0M0 (n = 25), N1M0 (n = 2), N2M0 (n = 1), and N0M1 (n = 1) disease. Most tumors were invasive ductal carcinoma (IDC), low to intermediate grade, estrogen receptor (ER) and progesterone receptor (PR) positive and HER2 negative (23 tumors, 68%). Tumor size ranged from 0.4-1.9 (median 0.8) cm for curative cryoablation and 0.6-6.0 (median 1.3) cm for palliative cryoablation. For 27 patients with follow-up imaging, ablation was curative in 14 patients, 14 tumors and palliative in 13 patients, 18 lesions. Imaging follow-up time ranged from 3 to 26 (median 16) months, > 12 months in 22 of 27 patients and 25 of 32 tumors. Complications were limited to 2 cases of skin frost injury, 1 mild and 1 moderate. Treatment success was achieved in 13 of 14 patients with curative and all 13 patients with palliative cryoablation.

CONCLUSION

Our study defines treatment success for curative and palliative breast cryoablation, demonstrates breast cryoablation achieves not only procedure (technical) but also patient-specific treatment objectives without significant complications, and may serve as guide for integrating breast cryoablation in the treatment of breast cancer patients.

Imaging the dense breast

The sensitivity of mammography reduces as breast density increases, which impacts breast screening and locoregional staging in breast cancer. Supplementary imaging with other modalities can offer improved cancer detection, but this often comes at the cost of more false positives. Magnetic resonance imaging and contrast-enhanced mammography, which assess tumour enhancement following contrast administration, are more sensitive than digital breast tomosynthesis and ultrasound, which predominantly rely on the assessment of tumour morphology.

Patient Experience of Women With Dense Breasts Undergoing Screening Contrast-Enhanced Mammography

OBJECTIVE

We investigated patient experience with screening contrast-enhanced mammography (CEM) to determine whether a general population of women with dense breasts would accept CEM in a screening setting.

METHODS

In this institutional review board-approved prospective study, patients with heterogeneous and extremely dense breasts on their mammogram were invited to undergo screening CEM and complete pre-CEM and post-CEM surveys. On the pre-CEM survey, patients were asked about their attitudes regarding supplemental screening in general. On the post-CEM survey, patients were asked about their experience undergoing screening CEM, including causes and severity of any discomfort and whether they would consider undergoing screening CEM again in the future or recommend it to a friend.

RESULTS

One hundred sixty-three women were surveyed before and after screening CEM. Most patients, 97.5% (159/163), reported minimal or no unpleasantness associated with undergoing screening CEM. In addition, 91.4% (149/163) said they would probably or very likely undergo screening CEM in the future if it cost the same as a traditional screening mammogram, and 95.1% (155/163) said they would probably or very likely recommend screening CEM to a friend. Patients in this study, who were all willing to undergo CEM, more frequently reported a family history of breast cancer than a comparison cohort of women with dense breasts (58.2% vs 47.1%, P = .027).

CONCLUSION

Patients from a general population of women with dense breasts reported a positive experience undergoing screening CEM, suggesting screening CEM might be well received by this patient population, particularly if the cost was comparable with traditional screening mammography.

Inter-reader agreement of breast magnetic resonance imaging and contrast-enhanced mammography in breast cancer diagnosis: a multi-reader retrospective study

OBJECTIVE

Breast magnetic resonance imaging (MRI) and contrast-enhanced mammography (CEM) are nowadays used in breast imaging but studies about their inter-reader agreement are lacking. Therefore, we compared the inter-reader agreement of CEM and MRI in breast cancer diagnosis in the same patients.

METHODS

Breast MRI and CEM exams performed in a single center (09/2020-09/2021) for an IRB-approved study were retrospectively and independently evaluated by four radiologists of two different centers with different levels of experience who were blinded to the clinical and other imaging data. The reference standard was the histological diagnosis or at least 1-year negative imaging follow-up. Inter-reader agreement was examined using Cohen's and Fleiss' kappa (κ) statistics and compared with the Wald test.

RESULTS

Of the 750 patients, 395 met inclusion criteria (44.5 ± 14 years old), with 752 breasts available for CEM and MRI. Overall agreement was moderate (κ = 0.60) for MRI and substantial (κ = 0.74) for CEM. For expert readers, the agreement was substantial (κ = 0.77) for MRI and almost perfect (κ = 0.82) for CEM; for non-expert readers was fair (κ = 0.39); and for MRI and moderate (κ = 0.57) for CEM. Pairwise agreement between expert readers and non-expert readers was moderate (κ = 0.50) for breast MRI and substantial (κ = 0.74) for CEM and it showed a statistically superior agreement of the expert over the non-expert readers only for MRI (p = 0.011) and not for CEM (p = 0.062).

CONCLUSIONS

The agreement of CEM was superior to that of MRI (p = 0.012), including for both expert (p = 0.031) and non-expert readers (p = 0.005).