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Initial Clinical Experience With Contrast-Enhanced Digital Breast Tomosynthesis

Posted Jan 31, 2007 Updated Apr 7, 2023
By Sara C. Chen MD , Ann-Katherine Carton PhD , Michael Albert PhD , Emily F. Conant MD , Mitchell D. Schnall MD PhD , Andrew D.A. Maidment PhD
10 min read

Rationale and Objectives

Contrast-enhanced digital mammography and digital breast tomosynthesis are two imaging techniques that attempt to increase malignant breast lesion conspicuity. The combination of these into a single technique, contrast-enhanced digital breast tomosynthesis (CE-DBT), could potentially integrate the strengths of both. The objectives of this study were to assess the clinical feasibility of CE-DBT as an adjunct to digital mammography, and to correlate lesion enhancement characteristics and morphology obtained with CE-DBT to digital mammography, ultrasound, and magnetic resonance (MR).

Materials and Methods

CE-DBT (GE Senographe 2000D; Milwaukee, WI) was performed as a pilot study in an ongoing National Cancer Institute–funded grant (P01-CA85484) studying multimodality breast imaging. Thirteen patients with ACR BI-RADS category 4 or 5 breast lesions underwent imaging with digital mammography, ultrasound, MR, and CE-DBT. CE-DBT was performed at 49 kVp with a rhodium target and a 0.27-mm copper (Alfa Aesar, Ward Hill, MA) filter. Preinjection and postinjection DBT image sets were acquired in the medial lateral oblique projection with slight compression. Each image set consists of nine images acquired over a 50-degree arc and was obtained with a mean glandular x-ray dose comparable to two conventional mammographic views. Between the precontrast and postcontrast DBT image sets, a single bolus of iodinated contrast agent (1 ml/kg at 2 ml/s, Omnipaque-300; Amersham Health Inc., Princeton, NJ) was administered. Images were reconstructed using filtered-backprojection in 1-mm increments and transmitted to a clinical PACS workstation.

Results

Initial experience suggests that CE-DBT provides morphologic and vascular characteristics of breast lesions qualitatively concordant with that of digital mammography and MR.

Conclusion

As an adjunct to digital mammography, CE-DBT may be a potential alternative tool for breast lesion morphologic and vascular characterization.

Vascular neoangiogenesis has been shown to be essential for breast cancer growth ( ). Malignant breast tumor angiogenesis factors stimulate formation of disorganized vessel networks with abnormally increased vessel permeability ( ). As a result, the enhancement pattern of breast cancers with vascular contrast agents often differs from that of benign and normal breast tissues. This aspect of breast cancer biology has been most extensively illustrated with gadolinium-enhanced breast magnetic resonance (MR), which when applied clinically provides vascular characterization of breast lesions ( ).

X-ray techniques combined with contrast agents are also able to demonstrate this feature of breast cancer biology, as has been illustrated with digital subtraction angiography of the breast ( ) and contrast-enhanced CT of the breast ( ). Jong et al. ( ), Lewin et al. ( ), and Diekmann et al. ( ) have demonstrated that enhancement of breast cancers can be detected with contrast-enhanced digital mammography and that this technique can increase mammographic lesion conspicuity.

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Materials and methods

Patient Population

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Technique

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Imaging System

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Image Acquisition

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Image Processing and Reconstruction

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Results

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Table 1

Multimodality Imaging and Pathology Results

CE-DBT Case No. Column data Side Digital Mammography Ultrasound MR Pathology Precontrast DBT Postcontrast DBT 1 Left 9-mm group of calcifications; status post–core biopsy. 10 × 12 × 9 mm hypoechoic mass. 11-mm enhancing lesion; adjacent hematoma Infiltrating ductal carcinoma, 1.8 cm; biopsy site reaction Rounded density adjacent to biopsy clip Enhancing mass adjacent to postbiopsy seroma/hematoma 2 Left Focal asymmetry with 12-mm cluster of heterogeneous calcifications. Negative Negative Usual ductal hyperplasia without atypia Negative Negative 3 Right 3.2-cm focal asymmetry Multiple solid vascular masses 3.5-cm area of clumped enhancement Invasive ductal carcinoma Multiple masses Segmental, clumped enhancement 4 Right Postlumpectomy changes. Residual calcifications at margin. Postlumpectomy seroma 5-mm enhancing nodule at edge of seroma DCIS Seroma; otherwise negative Clumped enhancement at edge of seroma 5 Right 1.4-cm ill-defined asymmetry Irregular solid mass 1.3-cm enhancing mass Infiltrating ductal carcinoma Spiculated mass Enhancing spiculated mass 6 Left Two masses (1.6 cm and 3 cm), index lesion with biopsy clip Two irregular masses Two adjacent enhancing masses (combined size of 4.3 cm). Invasive ductal carcinoma Two adjacent masses Two enhancing masses 7 Right Postexcisional biopsy seroma Postexcisional biopsy seroma Clumped enhancement posterior to seroma 7.5 × 3.6 × 5.0-cm postbiopsy cavity; residual intraductal carcinoma Postexcisional biopsy seroma Enhancement posterior to seroma 8 Left Calcifications on film-screen only; digital mammogram negative 8-mm mass in medial breast Small mass with adjacent focus of enhancement in medial breast Invasive ductal carcinoma with DCIS No calcifications demonstrated Small foci of enhancement in central breast 9 Right Negative 2-cm mass in central breast; retroareolar fibroadenoma Enhancing 2-cm mass in central breast; retroareolar fibroadenoma Intraductal papilloma No suspicious finding No suspicious finding 10 Left 7-cm region of pleomorphic calcifications in lateral breast Large mass in lateral breast Large enhancing mass Extensive DCIS Large mass in upper outer quadrant Enhancing irregular mass in upper outer quadrant 11 Left 3.6-cm lobular mass in superior breast 3.6-cm lobular mass Enhancing 3.6-cm lobular mass Invasive lobular carcinoma Lobulated mass in upper breast Enhancing lobulated mass in upper breast 12 Right Postbiopsy changes; calcifications in superior and lateral breast Postbiopsy changes Postbiopsy changes DCIS at margins of postbiopsy cavity Postbiopsy changes Postbiopsy changes 13 Left Small mass in upper outer quadrant Mass in lateral breast 10 × 9 mm enhancing mass in lateral breast Invasive ductal carcinoma with DCIS Biopsy clip Small focus of faint enhancement adjacent to biopsy clip

Figure 1, Case 1: Digital mammogram ( A , left; B , right). In the left breast, there is a 9-mm cluster of calcifications inferoposterior to a clip from prior core biopsy ( arrow ). Just anterior to this cluster there is a focal asymmetry related to the recent biopsy. Right breast provided for comparison.

Figure 2, Case 1: MR, pregadolinium T1-weighted fat-suppressed ( A, B ) and postgadolinium subtracted ( C, D ) MR images of the left breast. A , In the location of the cluster of calcifications identified on digital mammogram, there is a 1.1-cm mass that is isointense to glandular tissue ( arrow ). B , 5 mm laterally, there is an approximately 1- cm ovoid region of high signal focus representing a postbiopsy hematoma ( arrowhead ). The focal region of low signal intensity posterior to this hematoma represents the artifact from a titanium clip. C , Subtracted image through the mass seen in A demonstrates avid enhancement ( arrow ). There is a suspicious area of nodular rim enhancement. Pathology demonstrated infiltrating ductal carcinoma. D , Subtracted image through the area of the postbiopsy hematoma demonstrates no enhancement ( arrowhead ).

Figure 3, Case 1: CE-DBT. A , Inferoanterior to the biopsy clip, precontrast DBT demonstrates a density that is more conspicuous than on the digital mammogram ( arrowhead ). The cluster of calcifications identified on the digital mammogram is not well demonstrated here due to motion ( arrow ). B , Reconstructed postcontrast DBT images display an enhancing mass posterior to and separate from the density seen on precontrast images ( arrow ). This enhancing mass corresponds in location to the cluster of calcifications on mammography. The appearance corresponds to findings on breast MR ( Fig. 2 ), which demonstrates an enhancing suspicious mass adjacent to and separate from a nonenhancing postbiopsy hematoma ( arrowhea d).

Figure 4, Case 5: Digital mammogram ( A , left; B , right). In the right breast, there is a 1.4-cm ill-defined focal asymmetry overlying the pectoralis muscle ( arrow ). Left breast provided for comparison.

Figure 5, Case 5: MR. A , Precontrast T1-weighted fat-suppressed image demonstrates a spiculated mass in the superior right breast ( arrow ), corresponding to the asymmetry seen on digital mammogram. B , Postcontrast subtracted image of the mass demonstrates avid enhancement consistent with malignancy ( arrow ). Pathology demonstrated a 1.2-cm infiltrating ductal carcinoma.

Figure 6, Case 5: CE-DBT. A , Precontrast DBT demonstrates a spiculated mass in the upper right breast projecting over the pectoralis muscle and corresponding to the location of the focal asymmetry on the digital mammogram ( arrow ). The spiculated margins of the mass are more apparent on the reconstructed tomosynthesis images than on the digital mammogram. B , This spiculated mass displays avid nonionic contrast enhancement on CE-DBT. C , Subtracted reconstructed CE-DBT image highlights this enhancing, spiculated mass (zoomed image included). Highly suspicious rim enhancement is also seen on this subtraction image.

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Discussion

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Rationale for Technical Parameters

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Future directions for technical optimization

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Clinical context

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Practical applications

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Acknowledgments

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Academic Radiology, Volume 14, Issue 2
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