Contrast-enhanced mammography-guided biopsy: technical feasibility and first outcomes

Relative Costs and Outcomes of a Contrast-Enhanced Mammography-Guided Biopsy Trial

OBJECTIVE

To assess the performance and cost implications of contrast-enhanced mammography-guided biopsy (CEM Bx).

METHODS

This is a prospective study from May 5, 2021, to April 18, 2022, across 2 U.S. academic centers, evaluating technical success, patient/radiologist feedback, and operational factors of CEM Bx. Inclusion criteria included that patients be 40 years or older and recommended for biopsy with suspicious findings on contrast-enhanced mammography (CEM). Descriptive statistics are reported for clinical outcomes, length of procedure, and user and participant feedback. An estimate of cost was made by comparing general Medicare costs that are being billed for CEM Bx and post-clip mammogram ($475.48) to the Medicare costs of MRI-guided biopsy (MRI Bx) and post-clip placement mammogram ($845.94).

RESULTS

Eighty-two participants enrolled. Twenty-two were excluded at the time of CEM Bx (22/82, 27%). Sixty participants were included (mean age 57 years, range 33 to 81 years) with 63 suspicious CEM lesions. The malignancy rate was 22% (14/63). A technical success rate of 100% was achieved. Average CEM Bx time was 29% to 33% the average reported MRI-guided breast biopsy times (CEM Bx = 11 minutes; MRI Bx = 33 to 38 minutes), indicating operational efficiencies. A positive opinion of CEM Bx was reported by 78% of radiologists, 93% of technologists, and 98% of patients. The estimated cost for each CEM Bx was ~ 45% lower than MRI Bx.

CONCLUSION

CEM Bx demonstrates high success rates and satisfaction scores. CEM Bx resulted in shorter procedure times, enhanced operational efficiency, and ~45% reduction in costs compared with MRI Bx. As advancements continue, we anticipate CEM Bx will offer a cost-efficient and timely option for breast biopsy.

Contrast-Enhanced Mammography Implementation: Early Struggles and Successes

We used focus groups of radiologists who led the implementation of contrast-enhanced mammography (CEM) in their practice to identify barriers and strategies for adoption. Members of the Society of Breast Imaging in the United States who served as lead on CEM implementation were invited to participate in 2 separate focus groups. Ten breast imaging radiologists with varied geographic and practice type (60% academic, 30% private, and 10% community practice) participated. There were 4 major themes identified: patient selection, workflow, contrast, and billing. Patient selection varied widely among practices, with some limiting CEM to patients unable to obtain MRI and others routinely using CEM for diagnostic workup. Lack of Food and Drug Administration approval limited screening applications in some practices. Workflow challenges were numerous, and site-specific solutions were developed for ordering, scheduling, staffing, and intravenous access. There were universal concerns regarding contrast, including safe administration, response to reactions, and biopsy planning for findings only visible on CEM. Contrast reaction training, including conducting mock codes at some practices, helped alleviate concerns of the radiologists and technologists. Finally, billing was an administrative hurdle that influenced patient selection. Ample preparation is needed to successfully start a CEM program with particular attention to patient selection, workflow, contrast administration/reactions, and billing.

Evaluation of contrast-enhanced mammography (CEM) in the preoperative staging of breast cancer: large-scale single center experience, update to 1005 cases

PURPOSE

The purpose of this study was to assess the diagnostic performance of CEM in the preoperative staging of breast cancer in a large cohort of patients.

MATERIALS AND METHODS

A retrospective review of preoperative staging CEM exams was conducted at our centre between June 2016 and June 2021. We evaluated cases where CEM influenced the type of surgery, necessitated additional biopsies or imaging, and identified additional lesions. The sensitivity, specificity, positive and negative predictive values (PPV and NPV), and accuracy of CEM for the entire sample and each subgroup setting were calculated. A receiver operating characteristic (ROC) curve and multivariate analysis were performed.

RESULTS

991 women, mean age 61.3 years old [35-93], with 1005 malignant lesions were included. CEM led to additional imaging in 36.7% (364/991) women and to additional biopsies in 18.5% (183/991) women. CEM altered the initial surgical plan based on conventional imaging in 226 out of 991 patients (22.8%). CEM had a sensitivity in the whole population of 91.5% (204/223), specificity of 96.8% (757/782), PPV of 89.1% (204/229), NPV of 97.5% (757/776) and an accuracy of 95.6% (961/1005); the AUC of the ROC curve was 0.941. We found CEM better performed in patients with a low BPE level compared with a high BPE level (ρ = 0.028861). We see that the presence of additional lesions at CEM was the only significant predictor in the model.

CONCLUSION

This study reaffirms the high diagnostic accuracy of CEM for preoperative breast cancer staging in a large patient cohort.

Histopathological Analysis of Vacuum-Assisted Breast Biopsy in Relation to Microcalcification Findings on Mammography: A Pictorial Review

Mammography is an essential tool in breast screening, often revealing lesions that appear as microcalcifications with or without an associated mass. Decisions about biopsy requirements are guided by the BI-RADS system, aiming to confirm the histopathology of suspicious lesions while avoiding unnecessary procedures. A vacuum-assisted breast biopsy (VABB) is a minimally invasive procedure for diagnosing breast abnormalities. Precise lesion targeting is ensured under stereotactic guidance, reducing the need for repeated procedures. Compared to traditional core needle biopsy (CNB) and fine-needle aspiration cytology (FNAC), it differs in using vacuum assistance to gather more tissue volume, increasing diagnostic accuracy and reducing the likelihood of histological underestimation. This is particularly crucial in cases where microcalcifications are the primary finding, as they are often the earliest signs of ductal carcinoma in situ (DCIS). Managing such findings requires precise diagnostic tools to differentiate benign from malignant lesions without subjecting patients to unnecessary surgical interventions. Building on several years of experience in our department, we have assembled a selection of ten interesting cases encountered in our clinical practice. Each case is documented with paired mammographic images and their corresponding image of histopathological findings, offering a comprehensive view of the diagnostic journey. These cases were selected for their educational value, highlighting the integration of imaging modalities, histopathological evaluation, and clinical decision-making. All cases underwent an extensive diagnostic workup at our facility. This compilation aims to provide valuable insights for both clinicians and researchers, offering a deeper understanding of advanced diagnostic techniques and their role in improving patient outcomes.

Establishing Diagnostic Reference Levels for Mammography Digital Breast Tomosynthesis, Contrast Enhance, Implants, Spot Compression, Magnification and Stereotactic Biopsy in Dubai Health Sector

The aim of this patient dose review is to establish a thorough diagnostic reference level (DRL) system. This entails calculating a DRL value for each possible image technique/view considered to perform a diagnostic mammogram in our practice. Diagnostic mammographies from a total of 1191 patients who underwent a diagnostic mammogram study in our designated diagnostic mammography center were collected and retrospectively analyzed. The DRL representing our health sector was set as the median of the mean glandular dose (MGD) for each possible image technique/view, including the 2D standard bilateral craniocaudal (LCC/RCC) and mediolateral oblique (LMLO/RMLO), the 2D bilateral spot compression CC and MLO (RSCC/LSCC and RSMLO/LSMLO), the 2D bilateral spot compression with magnification (RMSCC/LMSCC and RMSMLO/LMSMLO), the 3D digital breast tomosynthesis CC and MLO (RCC/LCC and RMLO/LMLO), the 2D bilateral implant CC and MLO (RIMCC/LIMCC and RIMMLO/LIMMLO), the 2D bilateral contrast enhanced CC and MLO (RCECC/LCECC and RCEMLO/LCEMLO) and the 2D bilateral stereotactic biopsy guided CC (SBRCC/SBLCC). This patient dose review revealed that the highest MGD was associated with the 2D bilateral spot compression with magnification (MSCC/MSMLO) image view. For the compressed breast thickness (CBT) group 60-69 mm, the median and 75th percentile of the MGD values obtained were MSCC: 3.35 and 3.96, MSMLO: 4.14 and 5.25 mGy respectively. Obvious MGD variations were witnessed across the different possible views even for the same CBT group. Our results are in line with the published DRLs when using same statistical quantity and CBT group.

Comparison of Contrast-enhanced Mammography and Low-Energy Imaging with or without Supplemental Whole-Breast US in Breast Cancer Detection

Background Contrast-enhanced mammography (CEM) is an emerging modality that generates low-energy (LE) images that are visually equivalent to full-field digital mammography (FFDM) and recombined images that show lesion vascularity such as MRI. Supplemental whole-breast US increases cancer detection rates when performed with FFDM but not with MRI. Purpose To compare the performance of CEM, LE images, and LE images supplemented with whole-breast US in breast cancer detection during screening. Materials and Methods This prospective study recruited female participants from December 2014 to February 2019 who were scheduled for screening mammography and whole-breast US. CEM (including LE images and recombined images) and whole-breast US images were interpreted by separate breast radiologists blinded to the findings on images from the other modality. Statistical differences in sensitivity and specificity, positive predictive value (PPV), negative predictive value, and abnormal interpretation rate were assessed. Biopsy recommendation rate and PPVs of biopsies performed (PPV3) were calculated at the lesion level. Results Across 468 participants (median age, 54 years [IQR, 48-59 years]; all female participants), nine screen-detected cancers were diagnosed in eight participants: one cancer was depicted at LE imaging alone (cancer detection rate, 2.1 of 1000), four were depicted at LE imaging with whole-breast US (cancer detection rate, 8.5 of 1000), and eight were depicted at CEM (cancer detection rate, 17.1 of 1000; P < .05). The abnormal interpretation rate was 10.3% (48 of 468) for LE images, 13.7% (64 of 468) for LE images with whole-breast US, and 18.6% (87 of 468) for CEM (P < .001). The biopsy recommendation rate was 15.0 of 1000 for LE images, 38.4 of 1000 for LE images with whole-breast US, and 42.7 of 1000 for CEM. Seven biopsies were recommended based on LE images (PPV3 of one of seven [14.3%]), 18 biopsies based on LE images with whole-breast US (with a PPV3 of five of 18 [27.8%]), and 20 biopsies based on CEM (PPV3 of 9 of 20 [45.0%]). Conclusion Breast cancer detection improved with CEM compared with LE images alone or LE images with whole-breast US. ClinicalTrials.gov Identifier: NCT02310698 © RSNA, 2025 Supplemental material is available for this article.

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.

Contrast-enhanced mammography improves patient access to functional breast imaging

Imaging research pathways focus increasingly on the development of individualised approaches to breast cancer detection, diagnosis and management. Detection of breast cancer with X-ray mammography may fail in some cancer subtypes with limited changes in morphology/tissue density and in women with dense breasts. International organisations offer recommendations for contrast-enhanced breast imaging, as it provides superior sensitivity for screening, local staging and assessment of neoadjuvant treatment response, when compared with standard X-ray mammography (including tomosynthesis) and breast ultrasound. Arguably, the evidence base is stronger for contrast-enhanced MRI (CE-MRI). Unfortunately, patient access to breast MRI in rural and remote areas is limited by practical limitations and equipment licensing restrictions. Moreover, breast MRI is an expensive test, likely to be out of reach for many women. Contrast-enhanced mammography (CEM) offers an attractive alternative to improve patient access to functional breast imaging. It is a new type of digital, dual energy X-ray mammography that can be performed on most modern units, following a relatively inexpensive hard- and software upgrade. In this paper, we review the rapidly accumulating evidence that CEM can provide similar diagnostic accuracy to CE-MRI, though at a significantly lower cost and offering greater comfort to the patient. The adoption of CEM can help meet the anticipated increased demand for CE-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.

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.

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.

Future challenges of contrast media in radiology

Contrast media (CM) were first used soon after the discovery of X-rays in 1895. Ever since, continuous technological development and pharmaceutical research has led to tremendous progress in radiology, more available techniques and contrast media, and expanded knowledge around their indications. A greater prevalence of chronic diseases, population ageing, and the rise in diagnosis and survival times among cancer patients have resulted in a growing demand for diagnostic imaging and an increased consumption of CM. This article presents the main lines of research in CM development which seek to minimise toxicity and maximise efficacy, opening up new diagnostic and therapeutic possibilities through new molecules or nanomedicine. The sector, which is continuously evolving, faces challenges such as shortages and the need for more equitable and sustainable practices.

Recommendations of the German Radiological Society's breast imaging working group regarding breast MRI

· Breast MRI is an essential part of breast imaging. · The recommendations for performing breast MRI have been updated. · A table provides a compact and quick overview. More detailed comments supplement the table.. · The "classic" breast MRI can be performed based on the recommendations. Tips for special clinical questions, such as implant rupture, mammary duct pathology or local lymph node status, are included.. CITATION FORMAT: · Wenkel E, Wunderlich P, Fallenberg E et al. Aktualisierung der Empfehlungen der AG Mammadiagnostik der Deutschen Röntgengesellschaft zur Durchführung der Mamma-MRT. Fortschr Röntgenstr 2024; 196: 939 - 944.

Stereotactic biopsy with contrast-enhanced mammography: the initial Australian experience

INTRODUCTION

Contrast-enhanced mammography (CEM) and MRI detect 'contrast-only' lesions (COLs) occult on standard breast imaging (ultrasound and conventional mammography). Until recently, MRI was the only reliable method of biopsy. This study presents the first Australian experience with CEM-guided biopsy (CEMBx) and the lessons learnt.

METHODS

A prospective audit of the first 15 consecutive patients who underwent CEMBx for COLs was performed. Indications for contrast imaging, patient and lesion characteristics, procedural details, radiation dose and pathology data were collected.

RESULTS

The 15 women were aged 37-81 years (mean 59 years). Indications for contrast imaging were problem solving (n = 3), moderate risk screening (n = 2), cancer staging (n = 9) and symptoms (n = 1). The COLs were non-mass (n = 14), mass (n = 1) and an enhancing asymmetry (n = 1). For one patient, two lesions were sampled during the same event. All lesions enhanced and were successfully sampled followed by marker clip insertion. Most biopsies (87.5%) were performed with the breast in cranio-caudal compression using a horizontal approach. Procedural duration ranged from 13 to 33 min (mean 22 min). Radiation dose was similar to standard stereotactic biopsy. Post-biopsy hematomas occurred in three patients, none required intervention. Clip displacement occurred in three cases. Core biopsy histopathology results were benign (n = 8), malignant (n = 7) and a borderline breast lesion (BBL) (n = 1). Patient satisfaction rates were high. Imaging follow-up is ongoing.

CONCLUSIONS

CEMBx is a quick, safe and reliable alternative to MRIBx to sample COLs.

MRI only detected lesions: Can contrast enhanced mammography guided biopsy be an alternative method: Initial clinical findings

OBJECTIVE

This study aims to analyze our initial findings regarding CEM-guided stereotactic vacuum-assisted biopsy for MRI-only detected lesions and compare biopsy times by MRI-guided biopsy.

MATERIALS AND METHODS

In this retrospective analysis, CEM-guided biopsies of MRI-only detected breast lesions from December 2021 to June 2023were included. Patient demographics, breast density, lesion size, background parenchymal enhancement on CEM, lesion positioning, procedure duration, and number of scout views were documented. Initially, seven patients had CEM imaging before biopsy; for later cases, CEM scout views were used for simultaneous lesion depiction and targeting.

RESULTS

Two cases were excluded from the initial 28 patients with 29 lesions resulting in a total of 27 lesions in 26 women (mean age:44.96 years). Lesion sizes ranged from 4.5 to 41 mm, with two as masses and the remaining as non-mass enhancements. Histopathological results identified nine malignancies (33.3 %, 9/27), including invasive cancers (55.6 %, 5/9) and DCIS (44.4 %, 4/9). The biopsy PPV rate was 33.3 %. Benign lesions comprised 66.7 %, with 22.2 % high-risk lesions. The biopsy success rate was 93.1 % (27/29), and minor complications occurred in seven cases (25.9 %, 7/27), mainly small hematomas and one vasovagal reaction (3.7 %, 1/27). Median number of scout views required was 2, with no significant differences between cases with or without prior CEM (P = 0.8). Median duration time for biopsy was 14 min, significantly shorter than MRI-guided bx at the same institution (P < 0.001) by 24 min with predominantly upright positioning of the patient (88.9 %) and horizontal approach of the needle (92.6 %).

CONCLUSION

This study showed that CEM-guided biopsy is a feasible and safe alternative method and a faster solution for MRI-only detected enhancing lesions and can be accurately performed without the need for prior CEM imaging.

State-of-the-art for contrast-enhanced mammography

Contrast-enhanced mammography (CEM) is an emerging breast imaging technology with promise for breast cancer screening, diagnosis, and procedural guidance. However, best uses of CEM in comparison with other breast imaging modalities such as tomosynthesis, ultrasound, and MRI remain inconclusive in many clinical settings. This review article summarizes recent peer-reviewed literature, emphasizing retrospective reviews, prospective clinical trials, and meta-analyses published from 2020 to 2023. The intent of this article is to supplement prior comprehensive reviews and summarize the current state-of-the-art of CEM.

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.

Contrast-enhanced breast imaging: Current status and future challenges

BACKGROUND

Contrast-enhanced breast MRI and recently also contrast-enhanced mammography (CEM) are available for breast imaging. The aim of the current overview is to explore existing evidence and ongoing challenges of contrast-enhanced breast imaging.

METHODS

This narrative provides an introduction to the contrast-enhanced breast imaging modalities breast MRI and CEM. Underlying principle, techniques and BI-RADS reporting of both techniques are described and compared, and the following indications and ongoing challenges are discussed: problem-solving, high-risk screening, supplemental screening in women with extremely dense breast tissue, breast implants, neoadjuvant systemic therapy (NST) response monitoring, MRI-guided and CEM- guided biopsy.

RESULTS

Technique and reporting for breast MRI are standardised, for the newer CEM standardisation is in progress. Similarly, compared to other modalities, breast MRI is well established as superior for problem-solving, screening women at high risk, screening women with extremely dense breast tissue or with implants; and for monitoring response to NST. Furthermore, MRI-guided biopsy is a reliable technique with low long-term false negative rates. For CEM, data is as yet either absent or limited, but existing results in these settings are promising.

CONCLUSION

Contrast-enhanced breast imaging achieves highest diagnostic performance and should be considered essential. Of the two contrast-enhanced modalities, evidence of breast MRI superiority is ample, and preliminary results on CEM are promising, yet CEM warrants further study.

[Use of contrast-enhanced mammography for diagnosis of breast cancer]

BACKGROUND

Contrast-enhanced mammography (CEM) is an imaging method that is able to improve visualization of intramammary tumors after peripheral venous administration of an iodine-containing contrast medium (ICM).

OBJECTIVES AND METHODS

The current significance of CEM is discussed.

RESULTS

Studies were able to show an advantage of CEM in the diagnosis of breast cancer compared to mammography, especially for women with dense breasts. Indications for CEM currently depend on the availability of magnetic resonance imaging (MRI). If MRI is available, CEM is indicated in those cases when MRI cannot be performed. Use of CEM for breast cancer screening is currently viewed critically. This view can change when results and updated assessments of large CEM studies in Europe and USA become available. Patients must be informed about the use of an ICM. As ICM administration for CEM is carried out in a similar manner to established imaging methods, the authors expect the use of ICM for CEM to be unproblematic as long as general contraindications are adhered to.

CONCLUSIONS

In the future, CEM could have greater importance for the diagnosis of breast cancer, as this imaging method has diagnostic advantages compared to conventional mammography. A great advantage of CEM is its availability. For those who use breast MRI, CEM is helpful when MRI is not feasible due to contraindications or other reasons.

Short-term follow-up of contrast-enhanced mammography lesions after negative breast MRI in women with elevated breast cancer risk

PURPOSE

To determine the outcome of enhancing lesions detected on contrast-enhanced mammography (CEM) that had no correlate on magnetic resonance imaging (MRI) and underwent short-term follow-up CEM.

METHODS

In this retrospective single-center study, we identified patients with elevated breast cancer risk who had a CEM between 2014 and 2021 showing indeterminate enhancement on recombined images (BI-RADS 0, 3, 4) that had no correlate on subsequent MRI (performed within one month), and therefore underwent short-term follow-up CEM (performed within eight months). Medical records and imaging studies were reviewed to collect data on patient and lesion characteristics, and outcomes. Cancer incidence with 95% confidence interval (CI) was calculated.

RESULTS

This study included 71 women (median age 49 years) with 81 enhancing CEM lesions who underwent short-term follow-up CEM (median 6.2 months) after MRI reported no correlate. Of 81 lesions (median size = 0.7 cm), 73 (90%) were non-mass enhancement and 8 (10%) were enhancing masses. No sonographic correlate was identified for 75 lesions that had a same-day targeted ultrasound. Two cancers (2.5%, 95% CI 0.3-8.6) were diagnosed during the short-term follow-up period, one at 6-months (invasive ductal carcinoma) and one at 12-months (ductal carcinoma in situ). The remaining 79 lesions were benign at 6-month follow-up CEM and at one-year mammographic follow-up.

CONCLUSIONS

Follow-up CEM of MRI-occult lesions is prudent and may be reasonable to perform at one-year given the low incidence of cancer detected at six-months (one of 81) in our small study sample.

Future of Breast Radiology

The landscape of breast imaging has transformed significantly since mammography's introduction in the 1960s, accelerated by ultrasound and imageguided biopsies in the 1990s. The emergence of magnetic resonance imaging (MRI) in the 2000s added a valuable dimension to advanced imaging. Multimodality and multiparametric imaging have firmly established breast radiology's pivotal role in managing breast disorders. A shift from conventional to digital radiology emerged in the late 20th and early 21st centuries, enabling advanced techniques like digital breast tomosynthesis, contrast-enhanced mammography, and artificial intelligence (AI) integration. AI's impending integration into breast radiology may enhance diagnostics and workflows. It involves computer-aided diagnosis (CAD) algorithms, workflow support algorithms, and data processing algorithms. CAD systems, developed since the 1980s, optimize cancer detection rates by addressing false positives and negatives. Radiologists' roles will evolve into specialized clinicians collaborating with AI for efficient patient care and utilizing advanced techniques with multiparametric imaging and radiomics. Wearable technologies, non-contrast MRI, and innovative modalities like photoacoustic imaging show potential to enhance diagnostics. Imaging-guided therapy, notably cryotherapy, and theranostics, gains traction. Theranostics, integrating therapy and diagnostics, holds potential for precise treatment. Advanced imaging, AI, and novel therapies will revolutionize breast radiology, offering refined diagnostics and personalized treatments. Personalized screening, AI's role, and imaging-guided therapies will shape the future of breast radiology.

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

Contrast-enhanced mammography-guided biopsy (CEM-Bx), a novel technique for diagnosing suspicious enhanced lesions, was commercialized for clinical application in 2021; however, there are only a few publications documenting this technique in the existing literature. The aim of this study was to evaluate the procedural performance and preliminary outcomes of CEM-Bx performed in our hospital between from September 2021 to June 2022. We reviewed data of 12 women who underwent CEM-Bx during the study period, including their demographic and procedural characteristics, biopsy success rate, histopathological diagnosis, and average glandular dose (AGD). All women (mean age ± standard deviation: 54±6 years) showed enhanced breast lesions on CEM and underwent CEM-Bx within one week. The success rate of CEM-Bx was 100%. The vertical needle approach was used in a decubitus position (N=7, 58%), while the horizontal needle approach was used in an upright sitting position (N=5, 42%). The mean procedure time for the CEM-Bx was 17±6.3 min. The mean AGD was 14.3±12.3 mGy. Histopathologic examination revealed a malignancy rate of 66.7%. In summary, CEM-Bx is a feasible technique, with a high success rate of diagnosing contract-enhanced lesions.

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

Accumulating evidence shows that contrast-enhanced mammography (CEM) has higher diagnostic performance than digital mammography and ultrasound and comparable diagnostic performance to MRI for various indications. CEM also offers certain practical advantages for patients. Nevertheless, the clinical implementation of CEM has been limited because of a range of factors. This AJR Expert Panel Narrative Review explores such factors hindering CEM implementation. These factors include the following: the 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 needed when performing CEM examinations, incomplete availability of CEM-guided biopsy systems, and reimbursement challenges. Considerations that currently mitigate or are expected to mitigate these factors are also highlighted.

Contrast-Enhanced Mammography-Guided Breast Biopsy: Single-Center Experience

This prospective single-center study enrolled 50 women with 51 contrast-enhanced mammography (CEM)-enhancing lesions that lacked a sonographic or mammographic correlate. Trial participants underwent CEM-guided biopsy. Biopsy was technically successful for 46 lesions and was not performed for five nonvisualized lesions (all nonmass enhancement), yielding a cancellation rate of 9.8%. Mean biopsy time was 16.6 minutes. All biopsies revealed concordant pathology (25 benign, 10 high-risk, 11 malignant). No non-visualized or benign lesion yielded malignancy at follow-up.

Contrast Enhanced Mammography (CEM) Enhancing Asymmetry: Single-Center First Case Analysis

(1) Purpose: The latest Breast Imaging Reporting and Data System (BI-RADS) lexicon for CEM introduced a new descriptor, enhancing asymmetries (EAs). The purpose of this study was to determine which types of lesions were correlated with EAs. (2) Methods: A total of 3359 CEM exams, executed at AOUC Careggi in Florence, Italy between 2019 and 2021 were retrospectively assessed by two radiologists. For each of the EAs found, the size, the enhancing conspicuity (degree of enhancement relative to background described as low, moderate, or high), whether there was a corresponding finding in the traditional radiology images (US or mammography), the biopsy results when performed including any follow-up exams, and the presence of background parenchymal enhancement (BPE) of the normal breast tissue (minimal, mild, moderate, marked) were described. (3) Results: A total of 64 women were included, 36 of them underwent CEM for a preoperative staging assessment, and 28 for a problem-solving examination. Among the 64 EAs, 19/64 (29.69%) resulted in being category B5 (B5) lesions, 5/64 (7.81%) as category B3 (B3) lesions, and 40/64(62.50%) were negative or benign either after biopsy or second-look exams or follow-up. We assessed that EAs with higher enhancing conspicuity correlated significantly with a higher risk of B5 lesions (p: 0.0071), especially bigger ones (p: 0.0274). Conclusions: EAs can relate both with benign and tumoral lesions, and they need to be assessed as the other CEM descriptors, with re-evaluation of low-energy images and second-look exams, particularly larger EAs with higher enhancing conspicuity.

Costing analysis to introduce a contrast-enhanced mammography service to replace an existing breast MRI service for local staging of breast cancer

AIM

To assess the cost impact of switching from contrast-enhanced magnetic resonance imaging (CE-MRI) to contrast-enhanced spectral mammography (CESM) for loco-regional staging of breast cancer from a public healthcare perspective.

MATERIALS AND METHODS

The CE-MRI cost was obtained from the NHS reference cost. The CESM cost was calculated using a bottom-up approach including use of the machine, pump injector, contrast medium, image storage, and time allocation for staff reporting and cannulation. The cost of upgrading existing machines to CESM or purchasing new mammographic machines was obtained via national procurement. Other costs were obtained from local pharmacy, published unit cost data, or estimated based on surveys.

RESULTS

For large health boards in Scotland (≥500 cancers diagnosed per annum), the cost savings of switching from CE-MRI to CESM range from £64,069 to £81,570. For small health boards (<500 cancers diagnosed per annum), the cost savings of switching from CE-MRI to CESM range from £6,453 to £23,953. The cost savings are most sensitive to the number of tests conducted per year, and whether the existing mammography machine can be upgraded to CESM or not.

CONCLUSION

Switching from CE-MRI to CESM for loco-regional staging of breast cancer is likely to be cost saving for both large and small health boards in Scotland. Further research is urgently needed to confirm the non-inferiority of CESM to CE-MRI as a locoregional staging technique. The input data of this analysis can be updated when such results become available.