Contrast-enhanced mammography-guided biopsy: technique and initial outcomes

Contrast enhanced mammography (CEM) guided biopsy using a prone table: A retrospective analysis of the preliminary experience in a single CEM referral center

BACKGROUND

This study evaluates the procedural efficacy and patient experience of Contrast Enhanced Mammography (CEM)-guided biopsies performed in a prone position using the Giotto Class 30,000 system. The emphasis is on the procedural advantages and clinical outcomes for "enhancing-only lesions" (EOLs).

METHODS

A retrospective analysis of 524 CEM examinations conducted from December 2023 to June 2024 at a tertiary referral center was performed. Patients referred for pre-surgical staging or evaluation of inconclusive findings from conventional imaging were included. The study utilized dual-energy imaging and vacuum-assisted biopsy techniques, focusing on patients with at least one EOL identified in their initial CEM. Exclusions were based on the absence of a primary or follow-up CEM conducted at our facility Endpoints of this work included procedure efficiency which was evaluated in terms of technical success (biopsy completion with adequate sampling), dose distribution and timing and detection of additional lesions and patients' comfort evaluation, based on the rate of complications (hematomas) and procedure interruption due to patients' specific request or fainting events.

RESULTS

Among the evaluated cases, 37 EOLs were biopsied. The average procedure time was 15.8 min. Biopsies were successfully completed in 100% of cases. However, complications occurred in 27% of cases, primarily as hematomas and a significant histological finding rate of 97.3% was recorded.

CONCLUSIONS

The use of the Giotto Class 30,000 system for CEM-guided biopsies in a prone position demonstrated high procedural success and was well-tolerated by patients, highlighting its potential to enhance procedural comfort and efficiency. These preliminary results validate the innovative approach, though further studies are required to solidify these findings and explore long-term outcomes.

Contrast-Enhanced Stereotactic Biopsy (CESB): Patient selection and practical considerations

Since its introduction in 2012, contrast-enhanced mammography (CEM) has shown increased clinical relevance as a diagnostic tool in breast imaging. Its diagnostic accuracy is on par with breast MRI, rendering it a viable and potentially cost-effective alternative for breast MRI indications, especially in areas with lower accessibility to MRI. Like MRI, CEM occasionally shows 'CEM-only' lesions, i.e., areas of contrast enhancement without corresponding findings on low-energy images, ultrasound, or digital tomosynthesis. The current workaround usually consists of performing MRI-guided biopsy. However, contrast-enhanced stereotactic biopsy (CESB) offers a new alternative and has become commercially available since 2020. This narrative review will outline patient selection, the procedure, important considerations when performing CESB, and an overview of current literature.

Breast radiation dose with contrast-enhanced mammography-guided biopsy: a retrospective comparison with stereotactic and tomosynthesis guidance

OBJECTIVES

This retrospective study aimed to compare the average glandular dose (AGD) per acquisition in breast biopsies guided by contrast-enhanced mammography (CEM), conventional stereotactic breast biopsy (SBB), and digital breast tomosynthesis (DBT). The study also investigated the influence of compressed breast thickness (CBT) and density on AGD. Furthermore, the study aimed to estimate the AGD per procedure for each guidance modality.

METHODS

The study included 163 female patients (mean age 57 ± 10 years) who underwent mammography-guided biopsies using SBB (9%), DBT (65%), or CEM (26%) guidance. AGD and CBT data were extracted from DICOM headers, and breast density was visually assessed. Statistical analyses included two-sample t-tests and descriptive statistics.

RESULTS

Mean AGD per acquisition varied slightly among CEM (1.48 ± 0.22 mGy), SBB (1.49 ± 0.40 mGy), and DBT (1.55 ± 0.47 mGy), with CEM presenting higher AGD at lower CBTs and less dose escalation at higher CBTs. For CBT > 55 mm, CEM showed reduced AGD compared to SBB and DBT (p < 0.001). Breast density had minimal impact on AGD, except for category A. The estimated AGD per procedure was approximately 11.84 mGy for CEM, 11.92 mGy for SBB, and 6.2 mGy for DBT.

CONCLUSION

The study found mean AGD per acquisition to be similar for CEM and SBB, with DBT slightly higher. CEM demonstrated higher AGD at lower CBT but lower AGD at higher CBT, indicating reduced dose escalation with increasing thickness. While breast density had minimal overall impact, variations were noted in category A. DBT was more dose-efficient per procedure due to fewer acquisitions required.

CLINICAL RELEVANCE STATEMENT

CEM guidance provides effective lesion visualization within safe radiation limits, improving the precision of percutaneous image-guided breast interventions and supporting its potential consideration in a wider range of breast diagnostic procedures.

KEY POINTS

Limited data exist on the AGD using CEM guidance for breast biopsies. CEM and SBB exhibit similar AGD per acquisition; DBT demonstrated the lowest AGD per procedure. Radiation from CEM guidance fits within safe limits for percutaneous image-guided breast interventions.

The verification of the utility of a commercially available phantom combination for quality control in contrast-enhanced mammography

Contrast-enhanced mammography is being increasingly implemented clinically, providing much improved contrast between tumour and background structures, particularly in dense breasts. Although CEM is similar to conventional mammography it differs via an additional exposure with high energy X-rays (≥ 40 kVp) and subsequent image subtraction. Because of its special operational aspects, the CEM aspect of a CEM unit needs to be uniquely characterised and evaluated. This study aims to verify the utility of a commercially available phantom set (BR3D model 020 and CESM model 022 phantoms (CIRS, Norfolk, Virginia, USA)) in performing key CEM performance tests (linearity of system response with iodine concentration and background subtraction) on two models of CEM units in a clinical setting. The tests were successfully performed, yielding results similar to previously published studies. Further, similarities and differences in the two systems from different vendors were highlighted, knowledge of which may potentially facilitate optimisation of the systems.

Contrast-Enhanced Mammography-Guided Biopsy: Preliminary Results of a Single-Center Retrospective Experience

Background: CEM-guided breast biopsy is an advanced diagnostic procedure that takes advantage of the ability of CEM to enhance suspicious breast lesions. The aim pf this paper is to describe a single-center retrospective experience on CEM-guided breast biopsy in terms of procedural features and histological outcomes. Methods: 69 patients underwent the procedure. Patient age, breast density, presentation, dimensions, and lesion target enhancement were recorded. All the biopsy procedures were performed using a 7- or 10-gauge (G) vacuum-assisted biopsy needle. The procedural approach (horizontal or vertical) and the decubitus of the patient (lateral or in a sitting position) were noted. Results: A total of 69 patients underwent a CEM-guided biopsy. Suspicious lesions presented as mass enhancement in 35% of cases and non-mass enhancement in 65% of cases. The median size of the target lesions was 20 mm. The median procedural time for each biopsy was 10 ± 4 min. The patients were placed in a lateral decubitus position in 52% of cases and seated in 48% of cases. The most common approach was horizontal (57%). The mean AGD was 14.8 mGy. At histology, cancer detection rate was 28% (20/71). Conclusions: CEM-guided biopsy was feasible, with high procedure success rates and high tolerance by the patients.