Contrast-enhanced spectral mammography: Impact of the qualitative morphology descriptors on the diagnosis of breast lesions

doi:10.1016/j.ejrad.2015.03.005

European Journal of Radiology

Volume 84, Issue 6, June 2015, Pages 1049-1055

https://doi.org/10.1016/j.ejrad.2015.03.005 Get rights and content

Highlights

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We studied interpretation criteria for enhancing lesions on CESM.
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We evaluated the enhancement patterns of 211 breast lesions.
•
Our results proved that CESM minimized positive and negative falsies in DM.
•
The proposed CESM lexicon helped in characterization and categorization.

Abstract

Objective

To analyze the morphology and enhancement characteristics of breast lesions on contrast-enhanced spectral mammography (CESM) and to assess their impact on the differentiation between benign and malignant lesions.

Materials and method

This ethics committee approved study included 168 consecutive patients with 211 breast lesions over 18 months. Lesions classified as non-enhancing and enhancing and then the latter group was subdivided into mass and non-mass. Mass lesions descriptors included: shape, margins, pattern and degree of internal enhancement. Non-mass lesions descriptors included: distribution, pattern and degree of internal enhancement. The impact of each descriptor on diagnosis individually assessed using Chi test and the validity compared in both benign and malignant lesions. The overall performance of CESM were also calculated.

Results

The study included 102 benign (48.3%) and 109 malignant (51.7%) lesions. Enhancement was encountered in 145/211 (68.7%) lesions. They further classified into enhancing mass (99/145, 68.3%) and non-mass lesions (46/145, 31.7%). Contrast uptake was significantly more frequent in malignant breast lesions (p value ≤0.001). Irregular mass lesions with intense and heterogeneous enhancement patterns correlated with a malignant pathology (p value ≤0.001). CESM showed an overall sensitivity of 88.99% and specificity of 83.33%. The positive and negative likelihood ratios were 5.34 and 0.13 respectively.

Conclusion

The assessment of the morphology and enhancement characteristics of breast lesions on CESM enhances the performance of digital mammography in the differentiation between benign and malignant breast lesions.

Introduction

Up-to-date, mammography appears to be the most consistent method for the early detection of breast cancer; yet, it has both limited sensitivity and specificity in the detection and diagnosis of breast lesions, especially in dense breasts. Moreover the full extent of the disease may not be clearly depicted. In reference to this, mammography misses about 20% of invasive breast cancers [1], [2].

The use of an intravenous injected iodinated contrast agent could help increase the sensitivity of digital mammography by adding information on tumor angiogenesis. The contrast agent can be used to highlight areas of unusual blood flow. Two approaches have been made for clinical implementation of contrast-enhanced mammography, namely; single-energy (SE) and dual-energy (DE) imaging. In each technique, pairs of mammograms are acquired, which are then subtracted in order to cancel the appearance of healthy breast tissue and thus permit the sensitive detection and specific characterization of lesions [3].

In the single energy or temporal subtraction technique high-energy images are acquired before and after contrast medium injection while in the dual energy technique the acquisition of a pair of low and high-energy images occurs only after contrast medium injection. The dual energy technique does not provide information about the kinetics of tumor enhancement but allows the acquisition of multiple views of the same breast or bilateral examination and is less sensitive to patient motion than the temporal technique. This feature allows for better morphology assessment [4].

At present, there are no standardized interpretation criteria for the evaluation of breast lesions on CESM. The different patterns of contrast uptake and the morphology descriptors of enhancing lesions which allow characterization of benign and malignant breast lesions on CESM are still a subject of research.

In this study, the enhancement characteristics and morphology descriptors of breast lesions on contrast-enhanced spectral mammography (CESM) are analyzed to assess their impact on the differentiation between benign and malignant breast lesions.

Section snippets

Patients

This study is a retrospective analysis that included 168 consecutive patients with 211 breast lesions in the period from January 2012 to June 2013. The study was approved by the Scientific Research Review Board of the Radiology Department, and waiver of informed consent was applied for the used data of the included cases.

Indication of contrast injection was to (i) further evaluate heterogeneous dense breast parenchyma (27/211; 12.8%) or (ii) clarify already identified mammography abnormalities

Classification of lesions

The study included 211 breast lesions: 102/211 (48.3%) benign and 109/211 (51.7%) malignant. The reference standard was histopathology of core or surgical biopsy specimens in 128/211(60.7%) lesions and a scheduled follow-up study for 1 year in 83/211(28.9%) lesions that showed typical benign morphology descriptors.

Malignant lesions included: 81/211 (38.4%) invasive duct carcinomas (IDC), 4/211 (1.95%) invasive lobular carcinomas (ILC), 14/211 (6.6%) mixed invasive duct and lobular carcinoma,

Discussion

In 2001, Lewin et al. discussed a dual-energy approach to contrast digital mammography based on a weighted subtraction of two images; one below and the other above the K edge of iodine [6], [7].

The morphology enhancement characteristics of benign and malignant breast lesions on dual-energy CESM are still under investigation. In this manuscript we assessed the enhancement characteristic and morphology descriptors of breast lesions on CESM and their impact on differentiating benign from malignant

Conflict of interest

The authors have no conflict of interest to declare.

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Cited by (41)

BIRADS 4 – Is it possible to downgrade lesions that do not enhance on recombinant contrast-enhanced mammography images?
2023, European Journal of Radiology
Analysis of the morphology of lesions classified into the BI-RADS 4 category and assessment of the possibility of downgrade the BI-RADS category in those that did not show enhancement on recombinant contrast-enhanced mammography (CEM) images.
The retrospective, single-center study included 528 patients who underwent a core needle biopsy performed from January 2017 to November 2022 due to a breast lesion classified as BI-RADS 4 on CEM. Patients’ electronic records and imaging examinations were reviewed. Individual lesions were classified into the morphological categories of mass, non-mass, and microcalcifications. Sensitivity, specificity, positive as well as negative predictive values were calculated for the whole group and individual morphological categories. The influence of the lesions' diameter on the results was analyzed.
CEM NPV for the whole group was 93.9% (±95% CI: 90.0–96.4), for mass lesions 100% (±95% CI: 94.5–100), for non-mass lesions 97.8% (±95% CI: 87.0–99.9) and 87.9% (±95% CI: 80.3–93.0) for microcalcifications. Given that 230 out of 383 benign lesions were not contrast-enhancing, 60.1% of unnecessary CNBs would have been correctly avoided. CEM sensitivity for lesions < 20 mm was lower than for lesions ≥ 20 mm and was respectively 86.6% (±95% CI: 76.8–92.8) vs 94.6% (±95% CI: 86.0–98.2), respectively.
CEM is characterized by high sensitivity in the detection of malignant lesions in the case of lesions with mass and non-mass morphology. The high NPV for recombinant images suggests that in the case of these lesions, the lack of enhancement supports the benign nature of the lesion and may lead to a downgrade of the BI-RADS category.
Structured reports for contrast-enhanced spectral mammography
2022, Radiologia
La mamografía espectral con realce de contraste (CESM) es una modalidad radiológica emergente en el campo de la imagen mamaria, que aporta información morfológica y funcional. Ha demostrado ser útil en diferentes escenarios clínicos (pacientes sintomáticas, hallazgos no concluyentes en otras pruebas de imagen, o en enfermedad neoplásica conocida) y constituye una alternativa válida a la RM. La aplicación de los informes estructurados en radiología mamaria se ha establecido con éxito desde la generalización del sistema BI-RADS. La utilización de un lenguaje estandarizado facilita la comunicación entre profesionales y favorece una óptima categorización de los hallazgos. Esta estandarización permite además que se pueda dar una recomendación de manejo y se monitoricen los resultados. La CESM, al ser una técnica relativamente novedosa, carece de un léxico BI-RADS específico para su lectura. Varios autores han realizado propuestas de lectura de la CESM, siendo la más aceptada, la lectura combinada de las imágenes de baja y alta energía según los léxicos BI-RADS de la mamografía y la RM.
Contrast-enhanced spectral mammography (CESM) is a relatively new breast imaging modality that provides morphological and functional information. It has proven useful in different clinical scenarios (symptomatic patients, inconclusive findings on other imaging tests, known neoplastic disease) and constitutes a valid alternative to MRI. Structured reports have been successfully implemented in breast imaging since the BI-RADS was adopted. The use of standardized language facilitates communication among professionals and promotes the optimal characterization of the findings. This standardization also enables recommendations for the management and monitoring of results. Since CESM is a relatively new technique, there is no specific BI-RADS lexicon for its interpretation. Various authors have proposed approaches to reporting CESM; the most widely accepted of these combines reporting high- and low-energy images together according to the BI-RADS lexicons for mammography and MRI.
Quantifying lesion enhancement on contrast-enhanced mammography: a review of published data
2022, Clinical Radiology
Citation Excerpt :
A further paper found no significant correlation between histological type and enhancement intensity, although a slightly higher proportion of IDC demonstrated marked enhancement (57% versus 50%).15 Three papers considered the pattern of enhancement; defined as homogeneous, heterogeneous, or ring enhancement as per the BIRADS MRI lexicon.10–12 Chi et al.11 calculated malignant odd ratios (OR) and found lesions with heterogeneous enhancement tended to be malignant OR 3.228 (95% CI: 1.986–5.247), whereas those demonstrating homogeneous enhancement tended to be benign OR 0.287 (95% CI: 0.175–0.471).
To review and discuss the current published data on FUNCTIONAL DATA DERIVED FROM contrast-enhanced spectral mammography (CESM) for investigation of breast lesions.
Literature searches were conducted in MEDLINE and PUBMED. Due to the novel nature of CESM and sparsity of published literature pertaining to associated functional data, the Medical Subject Headings (MeSH) used were intentionally broad.
After inclusion and exclusion criteria, 23 papers were included; 13 pertained to assessment of intensity or pattern of lesion enhancement, and 10 considered textural analysis for lesion assessment, including those using computer-aided detection (CAD) software. Meta-analysis of data was not possible due to heterogeneity of methodology.
There is consistent evidence that benign lesions tend to demonstrate different enhancement characteristics to cancers, with benign lesions tending to demonstrate weaker, homogeneous contrast medium uptake. Limited evidence suggests malignant lesions exhibit “wash-out” or decreasing pattern of enhancement, and benign lesions a progressively enhancing one. The application of textural analysis and radiomics to CESM images shows promising results for differentiating benign and malignant lesions, with potential to predict immunohistological features. A large-scale multicentre study, ideally using multivendor CESM equipment, will be needed to confirm this.
Clinical utility of contrast-enhanced mammography: A literature review
2020, Revista de Senologia y Patologia Mamaria
La mamografía con contraste (CEM) es una nueva y prometedora técnica de imagen basada en la neovascularización de los tumores de manera similar a la resonancia magnética de la mama. Los resultados de los estudios clínicos muestran que su rendimiento diagnóstico es significativamente mejor que el de la mamografía digital convencional, y que sus valores de sensibilidad y especificidad la hacen comparable con la resonancia magnética. Sus usos actuales y los propuestos incluyen la evaluación adicional de pacientes sintomáticos o pacientes con exámenes previos anormales, la evaluación de la extensión local de los cánceres de mama recién diagnosticados, el seguimiento de la quimioterapia neoadyuvante y la detección del cáncer de mama en pacientes de alto riesgo. Aunque la técnica se aprobó para uso clínico en 2010, todavía es poco conocida. En esta revisión, presentamos la técnica CEM y sus resultados de rendimiento de diagnóstico comparados con la mamografía convencional y la resonancia magnética de la mama. También presentamos los diferentes escenarios en los que se puede utilizar con éxito, tanto en el diagnóstico de la enfermedad de mama, como en la estadificación local del cáncer de mama, así como su papel potencial en los programas de detección del cáncer de mama.
Contrast-enhanced mammography (CEM) is a promising new imaging technique based on neovascularisation of the tumour, similar to magnetic resonance imaging of the breast. The results of clinical studies show that its diagnostic performance is significantly better than that of conventional digital mammography, and that its sensitivity and specificity are comparable to those of magnetic resonance imaging. Its current and proposed uses include further evaluation of symptomatic patients or patients with abnormal results on previous examinations, assessment of the local extension of newly diagnosed breast tumours, follow-up of neoadjuvant chemotherapy and detection of breast cancer in high-risk patients. Although the technique was approved for clinical use in 2010, it is still little known. In this review, we present the technique of CEM and its results in terms of diagnostic performance compared with conventional mammography and breast MRI. We also discuss the various scenarios in which it can be used successfully, both in the diagnosis of breast disease and in the local staging of breast cancer, as well as its potential role in breast cancer screening programmes.
Evaluation of the applicability of BI-RADS® MRI for the interpretation of contrast-enhanced digital mammography
2019, Radiologia
Se plantea comprobar la utilidad del léxico BI-RADS® de la resonancia magnética de la mama (RMM) para la descripción morfológica y la categorización de las imágenes obtenidas mediante mamografía digital con realce de contraste (CESM) en comparación con el diagnóstico final.
Se incluyeron pacientes con lesiones de mama palpables o que necesitaban una aclaración de anormalidades previamente identificadas por otra técnica de diagnóstico por imagen, o una evaluación complementaria de parénquima mamario heterogéneamente denso. Tres radiólogos evaluaron de forma independiente las lesiones de mama estudiadas por CESM utilizando una plantilla que contenía los descriptores morfológicos cualitativos del léxico BI-RADS® de la RMM. En una segunda etapa, otros dos radiólogos experimentados proporcionaron una opinión consensuada sobre casos discrepantes. Los lectores también proporcionaron una clasificación en la escala BI-RADS® de 1 a 5 para cada una de las lesiones, tanto benignas como malignas. Todos los resultados se compararon con el estado real de la enfermedad (estándar de referencia apropiado para el tipo de lesión) y la significación estadística fue evaluada mediante la prueba de χ².
El estudio incluyó 218 lesiones benignas y 426 malignas. Hubo un alto acuerdo interobservador entre los tres radiólogos (valor de kappa de Fleiss-Cohen = 0,805; IC al 95% 0,728-0,837). De forma similar a lo que se ha descrito para la RMM, la evaluación de los descriptores morfológicos de las lesiones que dan efecto de masa mostró que las lesiones malignas tienden a presentar una forma irregular, con bordes espiculados o mal definidos y un patrón de realce intenso y heterogéneo (p < 0,001). Sin embargo, a diferencia de la RMM, el patrón de realce en anillo no se puede describir como un criterio independiente de malignidad con esta técnica. Con respecto a las lesiones que no dan efecto de masa, el único descriptor significativo fue la intensidad de la captación del medio de contraste (p < 0,05). La aplicación global del léxico BI-RADS® de la RMM para CESM permitió la clasificación adecuada del 85% de las categorías benignas (BI-RADS 1 y lesiones BI-RADS 2 y 3) y el 93% de las lesiones malignas (BI-RADS 4-5), que son valores similares a los descritos para RMM.
Los descriptores morfológicos del léxico BI-RADS® de la RMM se pueden aplicar al análisis morfológico de lesiones de mama estudiadas por CESM. Las discrepancias parciales en la interpretación no influyeron en la puntuación final de BI-RADS®, lo que permite una buena diferenciación de las lesiones benignas y malignas.
To determine the usefulness of BI-RADS® MRI for the morphological description and categorization of images obtained with contrast-enhanced digital mammography in comparison with the final diagnosis.
We included patients who had palpable breast lesions, those who needed clarification regarding abnormalities identified with another imaging technique, and those which needed a complementary evaluation of heterogeneously dense breast parenchyma. Three radiologists working independently used a template with the BI-RADS® MRI qualitative descriptors to evaluate the breast lesions studied with contrast-enhanced digital mammography. In a second phase, two other experienced radiologists reached a consensus about discrepant interpretations. Readers also classified each lesion (both benign and malignant lesions) on the BI-RADS® scale (1 – 5). All the results were compared with the real state of disease (determined by the appropriate gold standard for each type of lesion), and the statistical significance was assessed with the chi-square test.
A total of 218 benign lesions and 426 malignant lesions were included. The interobserver agreement among the three radiologists was high (Fleiss-Cohen kappa = 0.805; 95% CI: 0.728–0.837). Similarly to what has been reported about breast MRI, on contrast-enhanced digital mammography, malignant lesions with mass effect tended to have an irregular shape with spiculated or ill-defined margins and a pattern of intense and heterogeneous enhancement (p < 0.001). Nevertheless, unlike on breast MRI, ring enhancement was not an independent criterion of malignancy on contrast-enhanced digital mammography. For lesions without a mass effect, the only significant descriptor was the intensity of contrast material uptake (p < 0.05). Applying the BI-RADS® MRI material to contrast-enhanced digital mammography images enabled the correct classification of 85% of lesions in the benign categories (BI-RADS 1 and BI-RADS 2 and 3 lesions) and of 93% of the lesions in the malignant categories (BI-RADS 4-5); these values are similar to those reported for breast MRI.
The morphological descriptors used in BI-RADS® MRI can be applied to the morphological analysis of breast lesions studied with contrast-enhanced digital mammography. The partial discrepancies in the interpretation did not influence the final BI-RADS® score, and the score enabled good differentiation between benign and malignant lesions.
Contrast-Enhanced Mammography-Guided Biopsy: Preliminary Results of a Single-Center Retrospective Experience
2024, Journal of Clinical Medicine

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View full text

Contrast-enhanced spectral mammography: Impact of the qualitative morphology descriptors on the diagnosis of breast lesions

Highlights

Abstract

Objective

Materials and method

Results

Conclusion

Introduction

Section snippets

Patients

Classification of lesions

Discussion

Conflict of interest

Eur J Radiol

Semin Roentgenol

Contrast-enhanced digital mammography: initial clinical experience

Radiology

Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations

Radiology

Anatomical noise in contrast-enhanced digital mammography. Part I. Single-energy imaging

Med Phys

ACR BI-RADS® mammography

ACR BI-RADS® Atlas, Breast imaging reporting and data system

Dual-energy contrast-enhanced digital subtraction mammography: development and clinical results of a new technique for breast cancer detection

Radiology

ACR BI-RADS^® mammography

ACR BI-RADS^® Atlas, Breast imaging reporting and data system