Background parenchymal enhancement in contrast-enhanced MR imaging suggests systemic effects of intrauterine contraceptive devices

Asymmetric background parenchymal enhancement on contrast-enhanced mammography: associated factors, diagnostic workup, and clinical outcome

OBJECTIVES

To summarize our institutional experience with contrast-enhanced mammography (CEM) exams reporting asymmetric background parenchymal enhancement (BPE).

MATERIALS AND METHODS

Consecutive CEMs performed between December 2012 and July 2023 were retrospectively reviewed to identify exams reporting asymmetric BPE. Associated factors, the level of reporting certainty, BI-RADS score, diagnostic workup, and clinical outcome were summarized. BPE grades and BI-RADS were compared between initial CEM vs. immediate MRI and 6-month follow-up CEM, when indicated, using the Sign test.

RESULTS

Overall, 175/12,856 (1.4%) CEMs (140 female patients, mean age, 46 ± 8.0 years) reported asymmetric BPE. Reporting certainty was mostly high (n = 86), then moderate (n = 59) and low (n = 30). Associated factors included contralateral irradiation (n = 94), recent ipsilateral breast treatment (n = 14), and unilateral breastfeeding (n = 4). BI-RADS scores were 0 (n = 21), 1/2 (n = 75), 3 (n = 67), 4 (n = 3), and 6 (n = 1), or given for a finding other than asymmetric BPE (n = 8). Initial diagnostic-workup often included targeted-US (n = 107). Immediate MRI (n = 65) and/or 6-month CEM follow-up (n = 69) downgraded most cases, with a significant decrease in BPE grade compared to the initial CEM (p < 0.01 for both). On follow-up, two underlying cancers were diagnosed in the area of questionable asymmetric BPE.

CONCLUSION

Apparent asymmetric BPE is most often a benign finding with an identifiable etiology. However, rarely, it may mask an underlying malignancy presenting as non-mass enhancement, thus requiring additional scrutiny.

CLINICAL RELEVANCE STATEMENT

The variability in the diagnostic-workup of apparent asymmetric background parenchymal enhancement stresses the clinical challenge of this radiological finding. Further studies are required to verify these initial observations and to establish standardized management guidelines.

KEY POINTS

Apparent asymmetric background parenchymal enhancement usually represents a benign clinical correlate, though rarely it may represent malignancy. Evaluation of asymmetric background parenchymal enhancement varied considerably in the metrics that were examined. Targeted US and MRI can be useful in evaluating unexplained asymmetric background parenchymal enhancement.

Intraindividual Comparison of Different Methods for Automated BPE Assessment at Breast MRI: A Call for Standardization

Background The level of background parenchymal enhancement (BPE) at breast MRI provides predictive and prognostic information and can have diagnostic implications. However, there is a lack of standardization regarding BPE assessment. Purpose To investigate how well results of quantitative BPE assessment methods correlate among themselves and with assessments made by radiologists experienced in breast MRI. Materials and Methods In this pseudoprospective analysis of 5773 breast MRI examinations from 3207 patients (mean age, 60 years ± 10 [SD]), the level of BPE was prospectively categorized according to the Breast Imaging Reporting and Data System by radiologists experienced in breast MRI. For automated extraction of BPE, fibroglandular tissue (FGT) was segmented in an automated pipeline. Four different published methods for automated quantitative BPE extractions were used: two methods (A and B) based on enhancement intensity and two methods (C and D) based on the volume of enhanced FGT. The results from all methods were correlated, and agreement was investigated in comparison with the respective radiologist-based categorization. For surrogate validation of BPE assessment, how accurately the methods distinguished premenopausal women with (n = 50) versus without (n = 896) antihormonal treatment was determined. Results Intensity-based methods (A and B) exhibited a correlation with radiologist-based categorization of 0.56 ± 0.01 and 0.55 ± 0.01, respectively, and volume-based methods (C and D) had a correlation of 0.52 ± 0.01 and 0.50 ± 0.01 (P < .001). There were notable correlation differences (P < .001) between the BPE determined with the four methods. Among the four quantitation methods, method D offered the highest accuracy for distinguishing women with versus without antihormonal therapy (P = .01). Conclusion Results of different methods for quantitative BPE assessment agree only moderately among themselves or with visual categories reported by experienced radiologists; intensity-based methods correlate more closely with radiologists' ratings than volume-based methods. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Mann in this issue.

Biological sex and hormonal contraceptive associations with drug cue reactivity in cannabis use disorder

Biological sex differences in Cannabis Use Disorder (CUD) progression, cannabis withdrawal severity, and pharmacotherapy response have been reported, suggesting that CUD mechanisms may differ by sex. Drug cue reactivity is an established predictor of drug use behavior, but the literature on sex differences in drug cue reactivity is mixed, including in CUD. One possible moderator of sex differences in drug cue reactivity is hormonal contraceptive (HC) use. The aim of the present study was to test whether sex differences in neural cannabis cue reactivity and craving varied by female HC use in a CUD sample. As part of a larger study, 152 adults reporting frequent cannabis use completed a drug cue reactivity task during electrocenphalogram recording. Late positive potential (LPP) amplitude modulation by cannabis cues was used to measure neural cue reactivity. Craving after the cue reactivity task was also assessed. Males (n = 74) and naturally-cycling females (n = 26), who did not differ from each other, showed significantly greater LPP enhancement to cannabis vs. neutral cues compared to HC-using females (n = 52), an effect mostly driven by neutral cues. Craving was significantly higher in naturally-cycling but not HC-using females compared to males, but only in covariate-unadjusted analyses. Exploratory analyses of HC and menstrual phase characteristics indicate a progesterone-related mechanism may underlie HC effects on cannabis cue reactivity. The present study's results suggest that mixed findings on drug cue reactivity sex differences may be due to variability in HC use, which has implications for sex-specific models of CUD progression and treatment.

Hormonal Therapies in Multiple Sclerosis: a Review of Clinical Data

PURPOSE OF REVIEW

Given the potential for exogenous hormones to influence risk and course of MS, this narrative review aims to summarize current knowledge from observational and interventional studies of exogenous hormones in humans with MS.

RECENT FINDINGS

Large randomized clinical trials for combined oral contraceptives and estriol both show modest effect on inflammatory activity, with the latter showing potential neuroprotective effect. After fertility treatment, large actively treated cohorts have not confirmed any elevated risk of relapse. Preclinical data suggest that androgens, selective estrogen receptor modulators (SERMs), and selective androgen receptor modulators (SARMs) may be neuroprotective but clinical data are lacking. Gender affirming treatment, particularly estrogen in trans-women, could possibly be associated with elevated risk of inflammation. For women with MS entering menopause, hormone therapy appears safe during the appropriate menopausal window, but its long-term effects on neuroprotection are unknown. Exogenous hormones, used in varied doses and for diverse indications, have variable effects on MS risk, inflammatory activity, and neuroprotection. Large randomized trials are needed before it is possible to determine the true effect of exogenous hormones in a condition as complex as MS.

Influence of menstrual cycle and hormonal contraceptive use on MS symptom fluctuations: A pilot study

BACKGROUND

In clinical practice, females with MS often report menstrually-related symptom fluctuations. Hypothetically, use of oral contraceptives (OCs) could reduce these fluctuations, particularly continuous OCs (11+ weeks of consistent exogenous hormones followed by 1 week placebo).

OBJECTIVES

To prospectively capture (1) whether neurologic and generalized symptoms vary with menstrual cycle phase and (2) whether type of contraception impacts symptom fluctuations.

METHODS

In this two-center pilot study, females with MS and a regular menstrual cycle prospectively tracked their menstrual cycles and completed symptom surveys for up to 6 months. Participants were categorized as 1) users of oral contraceptives, either a) cyclic or b) continuous, or 2) endogenously cycling, either c) hormonal intrauterine device (IUD) users or d) "none users" (e.g. no hormonal contraception; included condoms, copper IUD, tubal ligation, "fertility awareness methods"). There was no correction for multiple analyses.

RESULTS

Altogether, 47/70 participants (67%) provided >4 weeks of data and were included in the analyses. Mean (SD) age was 35.0 (0.9) years, median (IQR) EDSS was 1.5 (1-2) and mean (SD) SymptoMScreen score was 10.4 (9.6). For endogenously cycling patients (IUD and none users), fatigue (MFIS) was lower in the perimenstrual period than in the luteal period (p < 0.05). For continuous OC users, variability in symptoms was lower than for endogenously cycling females (MFIS: p < 0.01; Daily Hassles, from Uplift & Hassles Survey: p < 0.05) or cyclic OC users (MFIS: p < 0.001).

CONCLUSIONS

In this pilot study, symptom severity did not definitively fluctuate in relationship to the menstrual cycle in endogenously cycling participants. However, fatigue and daily hassles were less variable for participants using continuous OC than for cyclic OC users or no-OC users. Future confirmatory studies are warranted to further examine whether contraceptive choice can be leveraged to manage symptom fluctuation in cycling females with MS. Such studies could enroll larger cohorts over fewer cycles or employ incentivization and hormonal measurements to enhance participant retention and statistical power.

Effect of contraceptive hormonal therapy on mammographic breast density: A longitudinal cohort study

PURPOSE

Evaluate the longitudinal relationship between mammographic density and hormonal contraceptive use in late reproductive-aged women.

METHODS

Patients aged 35-50 years old who underwent 5 or more screening mammograms within a 7.5-year period between 2004 and 2019 in a single urban tertiary care center were randomly selected. Patients were categorized into four cohorts based on hormonal contraceptive exposure during a 2-year lead-in period and a 7.5-year study period: 1) never exposed, 2) always exposed, 3) interval hormonal contraceptive start, and 4) interval hormonal contraceptive stop. The primary outcome was difference in BI-RADS breast density category between initial and final mammograms.

RESULTS

Of the 708 patients included, long-term use of combined oral contraceptives or a levonorgestrel intrauterine device were not associated with an increase in breast density category over the 7.5-year study period, compared to those with no hormonal contraceptive exposure. Initiation of combined oral contraceptives was associated with an increase in breast density category (β = 0.31, P = 0.045); however, no difference in initial density category was noted between those exposed and those never exposed to combined oral contraceptives during the 2-year lead-in period, and discontinuation was not associated with a decrease in breast density category when compared to those with continuous exposure.

CONCLUSION(S)

Long-term use of combined oral contraceptives or a levonorgestrel intrauterine device was not associated with an increase in BI-RADS breast density category. Initiation of a combined oral contraceptive was associated with an increase in breast density category, although this may be a transient effect.