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Use of Contrast-Enhanced Spectral Mammography for Intramammary Cancer Staging

Posted Oct 31, 2014 Updated Apr 10, 2023
By Katrin S. Blum MD , Christian Rubbert MD , Britta Mathys MD , Gerald Antoch MD , Svjetlana Mohrmann MD , Silvia Obenauer MD
9 min read

Rationale and Objectives

To prospectively evaluate and compare the accuracy of contrast-enhanced spectral mammography (CESM) and ultrasound (US) in size measurement of breast cancer with histologic tumor sizes as gold standard.

Materials and Methods

Twenty women aged between 40–73 years (mean age, 57 ± 10 years) with histologically proven invasive ductal/lobular carcinomas were included in the study. Agreement between imaging tumor size (CESM and US) and histopathologic tumor size was evaluated with Bland–Altman analysis. Stereotactically guided vacuum biopsy was performed in four patients after CESM. Two independent reviewers described artifacts of CESM.

Results

Motion artifacts did not occur in the study. CESM-specific artifacts caused by scattered radiation mostly occurred in oblique view of CESM. Background enhancement of breast tissue was seen in four patients. Mean difference of tumor sizes was 0.3 mm (6.34%) between CESM and histology and −2.2 mm (−7.59%) between US and histology. Limits of agreement ranged from −18.9 to 19.48 mm for CESM and from −17.1 to 12.7 mm with US. Especially smaller tumors with a size <23 mm were measured more precisely with CESM. Enhancement of breast tissue around microcalcifications correlated with abnormalities.

Conclusions

CESM is accurate in size measurements of small breast tumors. On average CESM leads to a slight overestimation of tumor size, whereas US tends to underestimate tumor size. Assessment of the breast tissue can be limited by the scattered radiation artifact and background enhancement of breast tissue. CESM seems to be helpful in the characterization of breast tissue around microcalcifications.

Contrast-enhanced spectral mammography (CESM) is an imaging technique combining digital mammography with intravenous injection of iodinated contrast media to detect hypervascularized lesions, especially in dense breast tissue . Although it was developed several years ago, knowledge about the performance of this technique in clinical routine, especially in breast cancer screening, is still limited. However, a recent study proposes similar indications for CESM as for magnetic resonance imaging (MRI), namely preoperative staging, detection of occult lesions, monitoring of treatment response . Initial results comparing this new technique with mammography, ultrasound (US) and breast MRI show a better detection of suspicious lesions with CESM compared to full-field digital mammography and the combined imaging of mammography and US but a lower detection rate of hypervascularized breast lesions compared to breast MRI . Studies evaluating the accuracy of CESM compared to MRI in preoperative tumor staging show a similar accuracy in lesion size measurement compared to MRI .

Preoperative staging of cancer extent in the breast is necessary to plan the optimal treatment . MRI is the most commonly used approach to determine the extent of the tumor in the breast and to decide which surgery should be performed and if the breast should be radiated . Besides its high cost and limited availability, one major problem of breast MRI is background enhancement of breast tissue, which decreases the detection of breast lesions and affects breast cancer staging . In such patients, US is a good alternative method for breast cancer staging. Studies correlating tumor size determined with imaging and histopathology describe a tendency to underestimate tumor size with US , whereas MRI tends to overestimate tumor size . The good performance of CESM in the detection of multifocal and multicentric cancer dissemination has been shown , as well as the high accuracy of tumor size measurements with CESM compared to MRI . The performance of CESM in preoperative tumor size measurement compared to US has not been investigated so far.

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Material and methods

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Patients

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CESM Imaging

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Ultrasound

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Image Analysis

Contrast-Enhanced Spectral Mammography

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Statistical Analysis

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Results

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Table 1

Details of Patients Included in the Study

Number of Patients Age (Mean Age; Standard Deviation) Disease ACR (Artifacts) ACR2 ACR3 ACR 4 20 40–73 (57; 10) Invasive cancer 2 4 1 Invasive cancer with EIC 4 (1) 6 3 (2)

The majority of patients had invasive cancer with additional extensive in-situ component (EIC).

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Artifacts

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Figure 1, Low-energy mammography (a) and processed CESM (b) oblique mammography (RMLO) and craniocaudal view (RCC; c and d ) of the right breast of a woman with invasive ductal breast cancer. Scattered radiation artifact is marked with arrows , appears more prominent in RMLO view, and does not affect tumor size measurement. CESM, contrast-enhanced spectral mammography; RCC, right craniocaudal; RMLO, right mediolateral.

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Background Parenchymal Enhancement of Breast Tissue

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Figure 2, Processed contrast-enhanced spectral mammography in (a) craniocaudal (LCC) and (b) oblique view (LMLO) in a woman with invasive ductal breast cancer with additional extensive intraductal component. The arrows mark the tumor; asterisks (*) mark enhancing foci retroareolar. Additional non-mass enhancement medial in the breast (**) is caused most likely because of hormonal proliferation. LCC, left craniocaudal; LMLO, left mediolateral.

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CESM Before Stereotactically Guided Vacuum-Assisted Core Biopsy of the Breast

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Figure 3, (a) Low-energy mammography of contrast-enhanced spectral mammography (CESM) of a woman with histological proven cancer in the upper part of the breast with suspicious microcalcifications (*). Additional suspicious microcalcifications are detected in the anterior third of breast tissue in the upper part of the breast ( arrow in the magnification of a in b ). Processed CESM image (c) with enhancement of the tumor and around the additional microcalcifications ( arrow in the magnification of c in d ). (e) Stereotactic-guided vacuum biopsy of the additional microcalcification, which turned out to be a ductal carcinoma in situ.

Table 2

Histopathologic Results of Four Patients with Suspicious Microcalcifications, Which Received CESM before Stereotactic-Guided Vacuum Biopsy

Patients Primary Cancer Type Enhancement Around Microcalcifications Histopathologic Finding Invasive lobular cancer N Fibrocystic mastopathy, ductal hyperplasia, and sclerosing adenosis N Fibrocystic mastopathy, ductal hyperplasia, and sclerosing adenosis Invasive ductal cancer N Fibrocystic mastopathy, ductal hyperplasia, and chronic inflammation Invasive ductal cancer Y Atypical lobular hyperplasia (ALH) ∗ N Fibrocystic mastopathy and ductal hyperplasia Invasive ductal cancer Y DCIS ∗

CESM, contrast-enhanced spectral mammography; DCIS, ductal carcinoma in situ.

CESM showed enhancement surrounding microcalcifications in two patients, one with DCIS and one with ALH. Both lesions were excised.

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No Significant Influence of Additional EIC on Tumor Size Measurements of Invasive Breast Cancers

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Table 3

Comparison of the Differences Between Measured Tumor Size with Imaging and Histopathology

Tumor Type Ultrasound CESM Mean (mm) LOA (mm) Mean (mm) LOA (mm) Invasive cancer ( n = 7) −1.571 −19.48 to 14.4 −0.714 −11.15 to 9.72 Invasive cancer + EIC ( n = 13) −2.538 −12.82 to 9.67 0.846 −22.06 to 23.75 Total ( n = 20) −2.2 −17.1 to 12.7 0.3 −18.88 to 19.48

CESM, contrast-enhanced spectral mammography; EIC, extensive in situ component; LOA, limits of agreement.

t Test showed no significant under- or over-estimation of tumor size ( P < .05).

Figure 4, Bland–Altman analysis of agreement of histologic tumor size with size measurements with contrast-enhanced spectral mammography (CESM) and ultrasound (US) in patients with invasive breast cancer with or without extensive intraductal component (EIC). High agreement of histologic tumor size and CESM measurements in patients with smaller tumors (≤22 mm). Additional EIC component did not affect tumor size measurements in either way.

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Discussion

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Academic Radiology, Volume 21, Issue 11
Journals General Radiology
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