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Contrast-enhanced Spectral Mammography

Posted Dec 31, 2016 Updated Apr 10, 2023
By Chni Bhimani DO , Luna Li MD PhD , Lydia Liao MD PhD MPH , Robyn G Roth MD , Elizabeth Tinney RRA , Pauline Germaine DO
4 min read

Rationale and Objectives

Contrast-enhanced spectral mammography (CESM) uses full field digital mammography with the added benefit of intravenous contrast administration to significantly reduce false-positive and false-negative results and improve specificity while maintaining high sensitivity. For CESM to fulfill its purpose, one should be aware of possible artifacts and other factors which may interfere with image quality, and attention should be taken to minimize these factors.

Materials and Methods

This pictorial demonstration will depict types of artifacts detected and other factors that interfere with image acquisition in our practice since CESM implementation.

Results

Many of the artifacts and other factors we have encountered while using CESM have simple solutions to resolve them.

Conclusion

The illustrated artifacts and other factors interfering with image quality will serve as a useful reference to anyone using CESM.

Introduction

Contrast-enhanced spectral mammography (CESM) is a relatively new tool in breast imaging. It uses full field digital mammography (FFDM) with the added benefit of intravenous contrast administration to assess for the physiological properties of breast cancer . This technique received FDA clearance in 2011. At our institution, CESM has been in clinical use since November 2012 and serves as a valuable tool in high-risk screening, further evaluation of extremely dense breast tissue, diagnostic assessment of suspicious lesions, breast cancer staging, surgical planning, and assessment of chemotherapy response. The current article presents the artifacts and other factors that interfere with image acquisition we have encountered thus far and highlights the necessary steps to improve image quality. Although some of these artifacts are similar to those seen with FFDM, many are unique to CESM. As CESM use becomes more widespread, it is important to be able to recognize how image quality is affected, understand the significance, and know the necessary steps to take to mitigate the level of image degradation created by these artifacts and other factors .

Materials and Methods

This pictorial demonstration will display the types of artifacts and other factors detected in our practice since CESM implementation and are divided into three categories: factors related to FFDM, contrast administration, and CESM (Germaine et al., presented at the 2015 63rd annual meeting of the Association of University Radiologists).

CESM Modality-Specific Factors Affecting Image Quality

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Motion

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Figure 1, Motion. A 60-year-old woman with biopsy-proven invasive ductal carcinoma ( asterisk ) in the right breast underwent CESM as part of a staging workup. Respiratory motion artifact in the right MLO LE (left) and SI (right) is especially apparent at the edges of the mass and biopsy clip located centrally within the mass. CESM, contrast-enhanced spectral mammography; LE, low energy; MLO, mediolateral oblique; SI, subtraction image.

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Figure 2, Subject-related factors. (a) A 51-year-old woman with LE (left) and SI (right) in the CC projection has curvilinear lines projecting in the medial aspect of the left breast ( ovals ). This is related to patient's hair and is visible on both LE and SI, with more pronounced effect on the SI. (b) A 43-year-old woman with a small piece of gown overlying the lateral left breast ( ovals ) on the CC LE (left) and SI (right). CC, craniocaudal; LE, low energy; SI, subtraction image.

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Air Artifact

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Figure 3, Air artifact. A 38-year-old woman has a history of bilateral breast reduction. The vertically oriented black lines ( ovals ) on the LE (left) and SI (right) in the inferior aspect of each breast on the MLO projections are accounted for by air trapped within the areas of surgical scarring in the inframammary folds. LE, low energy; MLO, mediolateral oblique; SI, subtraction image.

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Contrast Splatter

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Figure 4, Contrast splatter. A 55-year-old woman underwent CESM examination. LE (left) and SI (right) of the right breast in the CC projection show small droplets of contrast splattered on the detector plate before starting the CESM examination. Splattered droplets of contrast are detected on SI as small white dots simulating appearance of microcalcifications ( black circle and arrow ); no corollary abnormality is detected at the same level on the LE image ( black circle ). It should be noted that although microcalcifications are of white density on FFDM and LE CESM, they appear black on SI ( white circle and arrow ). CC, craniocaudal; CESM, contrast-enhanced spectral mammography; FFDM, full field digital mammography; LE, low energy; SI, subtraction image.

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Abnormal Timing of Contrast Bolus

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Figure 5, Abnormal timing of contrast bolus. A 76-year-old woman underwent CESM as part of a staging workup of the left breast mass. Abnormal enhancement in the lateral left breast ( black arrow ) on the CC SI obtained 2 minutes after contrast injection represents biopsy-proven invasive ductal carcinoma. Spot compression view in the CC projection of the same area obtained at 6 minutes reveals near complete washout of contrast ( white arrow ). CC, craniocaudal; CESM, contrast-enhanced spectral mammography; SI, subtraction image.

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Transient Retention of Contrast in Vein

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Figure 6, Transient retention of contrast in vein. (a) A 63-year-old woman whose avidly enhancing mass in the deep posterior lateral right breast ( arrow ) represents biopsy-proven invasive ductal carcinoma. Linear branching hyperdensities, most pronounced in the lateral aspect of the right breast just anterior to the mass, represent mild transient retention of intravenous contrast in the veins ( ovals ). This phenomenon usually disappears by the time the ipsilateral MLO projection is obtained. (b) A 51-year-old woman with an indwelling cardiac device deep in the left axilla underwent CESM instead of MRI; MLO projections show bilateral venous distention ( arrows ) with moderate amount of retained contrast. CESM, contrast-enhanced spectral mammography; MLO, mediolateral oblique; MRI, magnetic resonance imaging.

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Negative Contrast Enhancement

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Figure 7, Negative contrast enhancement. A 53-year-old woman with heterogeneously dense breast parenchyma underwent CESM, revealing the presence of two cysts ( arrows ) in the lateral aspect of the left breast on the SI (right), not appreciated on LE (left). CESM, contrast-enhanced spectral mammography; LE, low energy; SI, subtraction image.

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Halo Artifact

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Figure 8, Halo artifact. (a) A 56-year-old woman has a biopsy-proven invasive ductal carcinoma deep in the left breast ( circle ). Bilateral SI in CC projections demonstrates halo artifact ( arrows ) on both sides. In this case, the artifact does not affect image interpretation, as the enhancing mass is deep in the left breast ( oval ), away from the location of the artifact. (b) A 63-year-old woman whose bilateral SI in CC and MLO projections shows increased asymmetric enhancement in the central retroareolar left breast paralleling the halo artifact ( arrows ). Small parenchymal cysts were visualized on the accompanying ultrasound (not shown), suggesting parenchymal enhancement in the area of fibrocystic change. Repeat CESM examination in 6 months demonstrated resolution of this finding, supporting benign etiology. CC, craniocaudal; CESM, contrast-enhanced spectral mammography; MLO, mediolateral oblique; SI, subtraction image.

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Ripple Artifact

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Figure 9, Ripple artifact. A 65-year-old woman had CESM due to abnormal findings in the right breast on screening mammography. Faint alternating black and white lines on MLO SI (right) represents ripple artifact ( oval ), likely related to cardiac pulsations. This finding is not apparent on the accompanying MLO LE (left). Two biopsy clips are also present in the left breast in addition to several large calcifications, with negative density on the SI. CESM, contrast-enhanced spectral mammography; LE, low energy; MLO, mediolateral oblique; SI, subtraction image.

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Aborted Study

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Figure 10, Aborted study. (a) A 58-year-old woman underwent CESM as part of a diagnostic workup for a left breast palpable mass. Vertically oriented black lines on the MLO LE of the right breast were generated after the image acquisition was aborted midway. No SI was generated, as the study was aborted before the HE acquisition. (b) A 61-year-old woman with a similar example shows three vertical black lines on the LE acquisition of the left breast on spot MLO magnification view. No SI was generated. CESM, contrast-enhanced spectral mammography; HE, high energy; LE, low energy; MLO, mediolateral oblique; SI, subtraction image.

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Discussion

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References

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  • 5. Jochelson M.S., Dershaw D.D., Sung J.S., et. al.: Bilateral contrast-enhanced dual-energy digital mammography: feasibility and comparison with conventional digital mammography and MR imaging in women with known breast carcinoma. Radiology 2013; 266: pp. 743-751.

  • 6. Lobbes M.B., Smidt M.L., Houwers J., et. al.: Contrast-enhanced mammography: techniques, current results, and potential indications. Clin Radiol 2013; 68: pp. 935-944.

  • 7. Ayyala R.S., Chorlton M., Behrman R.H., et. al.: Digital mammographic artifacts on full-field systems: what are they and how do I fix them?. Radiographics 2008; 28: pp. 1999-2008.

  • 8. Geiser W.R., Haygood T.M., Santiago L., et. al.: Challenges in mammography: part 1, artifacts in digital mammography. Am J Roentgenol 2011; 197: pp. W1023-W1030.

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Academic Radiology, Volume 24, Issue 1
Journals General Radiology
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