Contrast-enhanced digital mammography

https://doi.org/10.1016/j.ejrad.2008.07.035Get rights and content

Abstract

CEDM is a recent development of digital mammography using the intra-venous injection of an iodinated contrast agent in conjunction with a mammography examination. Two techniques have been developed to perform CEDM examinations: the temporal subtraction technique with acquisition of high-energy images before and after contrast medium injection and the dual energy technique with acquisition of a pair of low and high-energy images only after contrast medium injection. The temporal subtraction technique offered the possibility to analyze the kinetic curve of enhancement of breast lesions, similarly to breast MRI. The dual energy technique do not provide information about the kinetic of tumor enhancement but allows the acquisition of multiples views of the same breast or bilateral examination and is less sensitive to patient motion than temporal CEDM. Initial clinical experience has shown the ability of CEDM to map the distribution of neovasculature induced by cancer using mammography. Moreover, previous studies have shown a superiority of MX + CEDM, either for the assessment of the probability of malignancy than for BIRADS assessment comparing to MX alone. The potential clinical applications are the clarification of mammographically equivocal lesions, the detection of occult lesions on standard mammography, particularly in dense breast, the determination of the extent of disease, the assessment of recurrent disease and the monitoring of the response to chemotherapy.

CEDM should result in a simple way to enhance the detection and the characterization of breast lesions.

Introduction

The clinical importance of tumor angiogenesis in primary breast cancer is well known. Studies have shown that intratumoral microvessel density is an independent prognostic indicator, and that it correlates with a higher incidence of metastases [1], [2]. Many methods for imaging angiogenesis in vivo have been developed in the last few years. First, digital subtraction angiography of the breast has been performed using an X-ray image intensifier system [3], [4]. Contrast medium has also been used with both CT and MR techniques to explore angiogenesis in breast carcinoma. Both techniques improve detection and characterization of breast carcinomas [5], [6], [7], [8], [9] and contrast-enhanced breast MRI with gadolinium-based agents is currently considered to be the most sensitive imaging technique for breast cancer detection. However, MR imaging is limited by its high cost and the limited access. At present, the development of digital mammography enables important new opportunities for the exploration of the breast using X-ray imaging. The primary benefit is a more reliable and efficient image management. The second main benefit is the ability to develop new clinical applications with the potential to improve breast cancer detection that were not possible with film-screen technology. Contrast-enhanced digital mammography (CEDM) with the injection of iodinated contrast medium is one of these clinical applications enabled by full-field digital mammography technology. First, we will present in this paper the both techniques that have been developed to perform CEDM examinations. We will describe the advantages and drawbacks of each technique. Then we will present the preliminary clinical experiences with these techniques. Finally we will discuss their potential clinical applications.

Section snippets

CEDM techniques

Two CEDM techniques are under development, the dual energy technique and the temporal technique.

Preliminary experiences with contrast-enhanced digital mammography

Encouraging technical and clinical results have been published during the last few years on using CEDM which suggest it may be a useful adjunct to mammography. Jong et al. [12] examined with temporal CEDM, 22 women who were to undergo biopsy for a suspicious lesion seen at imaging. Among the 22 women, there were 10 cancers. Eight of these (80%) showed enhancement on CEDM images. The two false negatives corresponded to 1 case of ductal carcinoma in situ and 1 case of invasive ductal carcinoma.

Conclusion

Initial clinical experience has shown the ability of CEDM to map the distribution of neovasculature induced by cancer at the high resolutions possible with digital mammography. CEDM should result in a simple way to enhance the detection of some breast cancers, to improve the characterization of breast lesion and to provide some prognostic factors of breast carcinoma. However, positive and negative predictive values should be prospectively evaluated on extensive clinical experience and in

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