The impact of contrast-enhanced spectral mammogram (CESM) and three-dimensional breast ultrasound (3DUS) on the characterization of the disease extend in cancer patients

Accuracy of different sonomammographic imaging modalities in assessment of breast tumor size

Background

Accurate breast cancer size is crucial for staging and an important prognostic factor in patient management. Therapeutic decisions heavily depend on tumor size detection by radiological imaging. The purpose of our prospective comparative study is to compare the diagnostic accuracy of different sonomammographic breast imaging modalities, namely DM, DBT, CESM, 2D US and 3D US in the preoperative tumor size measurement.

Results

CESM, 3D US and 2D US achieved moderately strong correlation with the pathological size measurements, while (DM) and (DBT) showed fair correlation with the pathology. CESM showed the highest correlation coefficient (0.789), while (DBT) showed the lowest correlation coefficient (0.411). Regarding the agreement, there was good agreement of the size measured by CESM, 3D US and 2D US with the pathology as the ICC was (0.798), (0.769) and (0.624), respectively. The highest agreement with the pathology was achieved with CESM. The agreement of the size measured by (DM) and (DBT) with the pathology was moderate as the ICC was (0.439) and (0.416), respectively. The lowest agreement was achieved with the size measured by (DBT).

Conclusions

CESM and 3D US are more superior to DM, 2D US and DBT regarding preoperative size measurement. 3D US can be used as preoperative noninvasive technique, especially in patients with impaired renal function who cannot tolerate CESM.

Comparison between second-look ultrasound and second-look digital breast tomosynthesis in the detection of additional lesions with presurgical CESM

OBJECTIVES

To compare second-look ultrasound (SL-ultrasound) with second-look digital breast tomosynthesis (SL-DBT) in the detection of additional lesions (ALs) with presurgical contrast-enhanced spectral mammography (CESM).

METHODS

We retrospectively included 121 women with 128 ALs from patients who underwent CESM for presurgical staging at our centre from September 2016 to December 2018. These ALs underwent SL-ultrasound and a retrospective review of DBT (SL-DBT) performed 1-3 weeks prior to CESM to evaluate the performance of each technique individually and in combination. ALs in CESM images were evaluated according to enhancement type (focus, mass, or non-mass), size (<10 mm or >10 mm) and level of suspicion (BI-RADS 2, 3, 4 or 5). Our gold-standard was post-biopsy histology, post-surgical specimen or >24 month negative follow-up. McNemar's test was used for the statistical analysis.

RESULTS

Out of the 128 ALs, an imaging correlate was found for 71 (55.5 %) with ultrasound, 79 (61.7%) with DBT, 53 (41.4 %) with DBT and ultrasound, and 97 (75.8%) with ultrasound and/or DBT. SL-DBT demonstrated a higher detection rate vs SL-ultrasound in non-mass enhancement (NME) pattern (p: 0.0325) and ductal carcinoma in situ histological type (p: 0.0081). Adding SL-DBT improved the performance vs SL-ultrasound alone in the overall sample (p: <0.0001) and in every subcategory identified; adding SL-ultrasound to SL-DBT improved the detectability of ALs in the overall sample and in every category except for NME (p: 0.0833), foci (p: 0.0833) and B3 lesions (p: 0.3173).

CONCLUSION

Combined second-look imaging (SL-DBT+ SL-ultrasound) for CESM ALs is superior to SL-DBT alone and SL-ultrasound alone. In B3 lesions, NME, and foci, the analysis of a larger sample could determine whether adding SL-ultrasound to SL-DBT is necessary or not.

ADVANCES IN KNOWLEDGE

Thanks to its high sensitivity, CESM is a useful tool in presurgical staging to detect the extent of the disease burden and identify ALs not detected with conventional imaging. Since CESM-guided biopsy systems are still scarcely available in clinical practice, it is necessary to look for other approaches to histologically characterize ALs detected with CESM. In our study, combined second-look imaging (SL-DBT + SL-ultrasound) showed better performance in terms of detectability of ALs, than either SL-DBT or SL-ultrasound alone, and allowed us to identify 91.2% of ALs that turned out to be malignant at final histology; for the remaining 8.8% it was still necessary to perform MRI or MRI-guided biopsy. However, this issue could be solved once CESM-guided biopsies spread in clinical practice. SL-DBT demonstrated a higher detection rate than SL-ultrasound in NME and ductal carcinoma in situ histology.

Contrast-Enhanced Mammography Implementation, Performance, and Use for Supplemental Breast Cancer Screening

Contrast-enhanced mammography (CEM) is an emerging breast imaging technology that provides recombined contrast-enhanced images of the breast in addition to low-energy images analogous to a 2-dimensional full-field digital mammogram. Because most breast imaging centers do not use CEM at this time, a detailed overview of CEM implementation and performance is presented. Thereafter, the potential use of CEM for supplemental screening is discussed in detail, given the importance of this topic for the future of the CEM community. Diagnostic performance, safety, and cost considerations of CEM for dense breast tissue supplemental screening are discussed.

Diagnostic value of the enhancement intensity and enhancement pattern of CESM to benign and malignant breast lesions

This study aimed to improve the diagnostic accuracy of breast diseases by combining breast imaging-reporting and data system (BI-RADS) with the enhancement intensity and pattern of contrast-enhanced spectral mammography (CESM) (this combination of BI-RADS and CESM was designated as BaC).BI-RADS was used to evaluate low-energy CESM images. Spearman nonparametric correlation analysis was performed to analyze the correlation between the enhancement intensity of CESM subtraction images and the pathological results. Odds ratio (OR) values were calculated to determine whether the enhancement pattern of CESM subtraction images is a risk factor for benign and malignant lesions. The diagnostic efficacies of BI-RADS, CESM, and BaC scores for benign and malignant breast diseases were analyzed using the receiver operating characteristic (ROC) curve.Lesions with a high enhancement intensity were more likely to be malignant than those with low enhancement intensity. Lesions with heterogeneous enhancement tended to be malignant, whereas those with homogeneous enhancement tended to be benign. No significant correlation was observed between ring enhancement and the benignity or malignancy of lesions. The area under the ROC curve of BaC was higher than that of BI-RADS or CESM, and the difference was statistically significant.The diagnostic efficacy of BI-RADS combined with CESM enhancement was superior to that of either method alone.

A review on methods for diagnosis of breast cancer cells and tissues

Breast cancer has seriously been threatening physical and mental health of women in the world, and its morbidity and mortality also show clearly upward trend in China over time. Through inquiry, we find that survival rate of patients with early‐stage breast cancer is significantly higher than those with middle‐ and late‐stage breast cancer, hence, it is essential to conduct research to quickly diagnose breast cancer. Until now, many methods for diagnosing breast cancer have been developed, mainly based on imaging and molecular biotechnology examination. These methods have great contributions in screening and confirmation of breast cancer. In this review article, we introduce and elaborate the advances of these methods, and then conclude some gold standard diagnostic methods for certain breast cancer patients. We lastly discuss how to choose the most suitable diagnostic methods for breast cancer patients. In general, this article not only summarizes application and development of these diagnostic methods, but also provides the guidance for researchers who work on diagnosis of breast cancer.

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.