To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls.Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar's test. Diagnostic performance was calculated considering lesions with available final histopathology.Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5-48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7-64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2-97.3%) and a 65.9% specificity (95% CI 51.1-78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images.Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity.• The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%. 

/pdf/contrast-enhanced-mammography-for-the-assessment-of-1wcswvbt.pdf

Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study

Background: To provide a systematic review and meta-analysis that evaluates the diagnostic accuracy of contrast-enhanced mammography (CEM) compared to standard contrast-enhanced breast magnetic resonance imaging (breast MRI). Like breast MRI, CEM enables tumour visualization by contrast accumulation. CEM seems to be a viable substitute for breast MRI. Methods: This systematic search assessed the diagnostic accuracy of these techniques in women with suspicious breast lesions on prior imaging or physical examination, who have undergone both breast MRI and CEM. CEM had to be performed on a commercially available system. The MRI sequence parameters had to be described sufficiently to ensure that standard breast MRI sequence protocols were used. Pooled values of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio (DOR), were estimated using bivariate mixed-effects logistic regression modeling. Hierarchical summary receiver operating characteristic curves for CEM and breast MRI were also constructed. Results: Six studies (607 patients with 775 lesions) met the predefined inclusion criteria. Pooled sensitivity was 96% for CEM and 97% for breast MRI. Pooled specificity was 77% for both modalities. DOR was 79.5 for CEM and 122.9 for breast MRI. Between-study heterogeneity expressed as the I2-index was substantial with values over 80%. Conclusion: Pooled sensitivity was high for both CEM and breast MRI, with moderate specificity. The pooled DOR estimates, however, indicate higher overall diagnostic performance of breast MRI compared to CEM. Nonetheless, current scientific evidence is too limited to prematurely discard CEM as an alternative for breast MRI.

/pdf/comparing-the-diagnostic-performance-of-contrast-enhanced-267jrjyb.pdf

Comparing the Diagnostic Performance of Contrast-Enhanced Mammography and Breast MRI: a Systematic Review and Meta-Analysis

Accumulating evidence shows that contrast-enhanced mammography (CEM) has higher diagnostic performance than digital mammography and ultrasound, and comparable diagnostic performance as MRI, for various indications. CEM also offers certain practical advantages for patients. Nevertheless, the clinical implementation of CEM has been limited due to a range of factors. This AJR Expert Panel Narrative Review explores such factors hindering CEM implementation. These include: risks of iodinated contrast media, increased radiation exposure, indications for which CEM is not the preferred test or for which further evidence is needed, workflow adjustments when performing CEM examinations, incomplete availability of CEM-guided biopsy systems, and reimbursement challenges. Considerations that currently or are expected to mitigate these factors are also highlighted.

Barriers to Implementation of Contrast-Enhanced Mammography in Clinical Practice: AJR Expert Panel Narrative Review.

Breast Imaging Reporting and Data System and Contrast Enhancement Mammography: Lesion Conspicuity Likelihood of Malignancy and Relationship With Breast Tumor Receptor Status.

Dual energy contrast-enhanced spectral mammography (CESM) technique has been introduced to overcome the standard mammography's performance on dense breasts. To enhance the visualization of the tumour, iodine contrast is used followed by an acquisition of images at low and high energies, which are then combined into a single image for additional information. This study used a model of a compressed breast made from clear resin with holes on the top. The holes were filled with iodine-based contrast and images with six different energies (50 kVp, 70 kVp, 80 kVp, 90 kVp, 100 kVp, 120 kVp) were obtained at a general purpose x-ray unit. Then, 15 subtraction images were calculated by performing a pixel by pixel subtraction of each possible image pair and the contrast was evaluated. The results indicated that the best contrast rates are achieved on 50 kVp and 70 kVp as low energy and 100 kVp and 120 kVp as high energy. The best contrast was evaluated for the pair 70–120 kVp.

Contrast Enhanced Radiography with a Printed Model

Contrast-enhanced mammography (CEM) is a combination of standard mammography and iodinated contrast material administration. During the last decade, CEM has found its place in breast imaging protoc...

Lidewij M.F.H. Neeter

Papers

Contrast-enhanced mammography: what the radiologist needs to know