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Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 855-861

Role of contrast-enhanced digital mammography in evaluation of breast lesions

1 Radiology Department, Faculty of Medicine, Menoufia University, Menoufia, Cairo, Egypt
2 Radiology Department, National Cancer Institute, Cairo University, Cairo, Egypt

Date of Submission02-Feb-2016
Date of Acceptance02-Mar-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Yasmin A Shaaban
Radiology Department, Faculty of Medicine, Menoufia University, Shibein El-Kom, Menoufia 32511
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_60_16

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The purpose of this study was to assess the role of dual-energy contrast mammography (MX) in evaluating breast lesions.
Contrast-enhanced digital mammography (CEDM) can significantly improve diagnostic quality such as clarification of mammographic and sonographic equivocal lesions, detection of occult lesions on MX, determination of the extent of disease, and assessment of recurrent disease.
Patients and methods
A total of 50 female patients were enrolled into the present study, with their ages ranging from 22 to 77 years (mean age of about 49.5), during the period between 2012 and 2014. All of them presented with benign or malignant breast lesions detected by sonomammography, categorized as Breast Imaging Reporting and Data System from 2 to 5. All were subjected to CEDM, and the images were obtained by a modified full-field digital MX system. The nonionic iodinated contrast agent was administered into the contralateral antecubital vein manually. The results were compared with the sonomammography results, and cases were histopathologically proven.
In our study, 37/50 cases were histopathologically proven as malignant and 16/50 were benign, whereas three patients had double pathology. Different patterns of enhancement were depicted on contrast-enhanced digital mammography (CEDM) in all histologically proven breast carcinomas. Our results show that sensitivity was higher for MX + CEDM (83.3%) compared with pathology and Breast Imaging Reporting and Data System analysis, respectively, with no loss in specificity. Compared with MX associated with breast ultrasound, CEDM had a better diagnostic accuracy mainly because of improved specificity and better positive and negative predictive values (positive predictive value and negative predictive value were 86 and 64.7%, respectively).
The addition of dual energy contrast-enhanced MX technique to conventional sonomammography can significantly improve diagnostic quality and cancer detection rate.

Keywords: breast lesions, contrast-enhanced digital mammography, mammography

How to cite this article:
Dessouky BA, Elsaid NA, Shaaban YA. Role of contrast-enhanced digital mammography in evaluation of breast lesions. Menoufia Med J 2017;30:855-61

How to cite this URL:
Dessouky BA, Elsaid NA, Shaaban YA. Role of contrast-enhanced digital mammography in evaluation of breast lesions. Menoufia Med J [serial online] 2017 [cited 2020 Jun 6];30:855-61. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/855/218299

  Introduction Top

Full-field digital mammography (FFDM) enables high-quality breast images with higher-contrast resolution, improved dynamic range, and rapid processing of data and images compared with screen film MX. FFDM has been shown to provide increased accuracy in screening premenopausal or perimenopausal women, women younger than 50, and women with dense breasts. Moreover, FFDM offers the possibility of developing new and advanced applications for breast imaging [1].

Contrast-enhanced digital mammography (CEDM) with injection of an iodinated contrast agent is one of them. Contrast agents have been used for many years in both computed tomography and MRI examinations to explore angiogenesis in breast carcinoma by tracking the uptake and washout of contrast agents in tissues [2].

Investigational clinical results on CEDM have been published during the last few years, suggesting that the technique may be a useful adjunct to MX with lesion contrast uptake information. Two CEDM examination techniques have been investigated: temporal subtraction and dual-energy CEDM [3],[4],[5],[6].


The aim of this study was to assess the role of CEDM in breast lesions.

  Patients and Methods Top

This study was prospectively carried out between May 2012 and August 2014 on a total of 50 consecutive female patients with palpable breast lesions. Their ages ranged from 22 to 77 years (mean age: 49.5 years). We excluded pregnant and lactating women, patients with renal impairment, patients with history of contrast agent allergy, patients with breast implants, and patients who were undergoing chemotherapy at the time of imaging.

The present study was approved by the ethics committee of our institution. Comprehensive explanation of the procedures was given to all patients, including the associated risks and contraindications, and then each patient signed an informed consent form.

All patients were subjected to the following:

  1. Clinical assessment: full history taking and physical examination of both breasts
  2. Laboratory investigations: kidney function tests
  3. Conventional mammography (MX) was first performed for all patients using a digital mammography device (Senographe 2000D Full-field Digital Mammography System; GE Healthcare, Chalfont St-Giles, UK) with a flat panel detector, a cesium iodide absorber, a field size of 19 × 23 cm, a 1.914 × 2.294 image matrix, and a del pitch of 100 μm. Basic craniocaudal and mediolateral oblique views were obtained for all patients, as well as other projections (such as lateral or spot views) when indicated
  4. CEDM was performed just after conventional mammographic studies for all the patients using the previously mentioned digital MX device.

An intravenous injection of 1.5 ml/kg body weight of nonionic contrast media (Omnipaque 350; Guerbet, Villepinte, France) was injected manually. Two minutes after initiation of contrast agent administration, the patient was positioned as for the conventional mammographic examination. The examined breast was compressed in the mediolateral oblique view, then in the craniocaudal position, and two pairs of low-energy and high-energy exposures were acquired. A specific software and hardware were used for rapid acquisition and processing of dual-energy iodine-enhanced images with contrast uptake information while canceling nonenhancing anatomic noise in the images.

Interpretation and analysis

Processed images were reviewed, and all lesions visible on MX and CEDM were verified and analyzed. MX images were carefully reviewed for the following:

  1. Masses: the number and site of masses were assessed. The border and margin of masses were categorized as ill-defined [Figure 1], well-defined [Figure 2], irregular, regular, or lobulated [Figure 3].
  2. Calcifications: they were defined as a cluster of microcalcifications, scattered microcalcifications, or macrocalcifications.
  3. Densities: defined as any asymmetry in the amount and density of both breast parenchyma and associated edema [Figure 1] or architecture distortion.
Figure 1: Ill-defined mass in mammography associated with edema pattern.

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Figure 2: Mediolateral oblique mammographic view showing a well-defined mass is seen at the upper outer quadrant.

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Figure 3: Mediolateral oblique mammographic view of a lobulated mass.

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All lesions identified during conventional MX were assessed after contrast media administration using CEDM images to confirm whether they were enhanced or not. Enhancing lesions were categorized into mass-like enhancement lesions [Figure 4] or non-mass-like enhancement lesions [Figure 5].
Figure 4: Contrast-enhanced digital mammography craniocaudal view showing multiple masses showing dense homogeneous mass like enhancement.

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Figure 5: Contrast-enhanced digital mammography mediolateral oblique view showing nonmass like enhancement.

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Pattern of enhancement was assessed as homogeneous, heterogeneous, or ring pattern as illustrated in [Figure 4], [Figure 6], and [Figure 7], and the degree of enhancement was assessed as faint or intense.
Figure 6: Contrast-enhanced digital mammography craniocaudal view showing marginal enhancement of simple cyst.

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Figure 7: Contrast-enhanced digital mammography craniocaudal view showing heterogeneous enhancement of a lobulated mass.

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We considered lesions with none or faint contrast uptake as benign, and lesions with intense contrast uptake as malignant. Ring enhancement with also detected in inflammatory and malignant lesions.

After analyzing the findings obtained by MX and contrast-enhanced MX, breast lesions were categorized using the Breast Imaging Reporting and Data System (BIRADS) assessment scale into BIRADS 1, negative; BIRADS 2, benign; BIRADS 3, probably benign; BIRADS 4, likely malignant; and BIRADS 5, malignant [Figure 8].
Figure 8: Breast Imaging Reporting and Data System (BIRDS) category of breast lesions.

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BIRADS classification on MX and CEDM of all detected lesions was compared with pathologic analysis of samples obtained by ultrasonography (US)-guided interventional procedures [fine needle aspiration cytology (FNAC) in 15 patients, core biopsy with true-cut needle biopsy in 22 patients, and surgical excision in 13 patients].

We considered lesions with BIRADS of at least 4 as positive for malignancy (positive group), and lesions with BIRADS less than or equal to 3 as negative for malignancy (negative group). Therefore, lesions visible on imaging (MX or CEDM) were divided into the following groups:

  1. True positive: BIRADS of at least 4 and proven cancer on histopathology
  2. False positive: BIRADS of at least 4 and benign lesion on histopathology
  3. False negative: BIRADS of less than or equal to 3 and proven cancer on histopathology
  4. True negative: BIRADS of less than or equal to 3 and benign lesion on histopathology.

Ultrasonography-guided biopsies

US-guided biopsies (FNAC and true-cut biopsy) using a superficial linear probe were obtained. The frequency ranged between 7 and 10 MHz. Ultrasound examination was carried out for diseased breasts and ipsilateral axilla. FNAC was performed on 15 patients, and the remaining 22 underwent true-cut biopsy studies.

  Results Top

The present study included 50 female patients, and their ages ranged from 22 to 77 years. Out of the studied 50 patients, 29 (48%) had single breast lesions, 21 (42%) patients had multiple breast lesions. Among patients with multiple breast lesions, 11 of them had lesions in the same breast, and 10 (20%) patients had bilateral breast lesions (three patients among them had double pathology). In patients with more than one breast lesion, the largest lesion of the same pathology was used for analysis. Therefore, the total number of breast lesions included for analysis was 53.

Final diagnoses of breast lesions by histopathology

Thirty-seven (69.8%) malignant lesions and 16 (30.1%) benign lesions were diagnosed. The diagnosed malignant lesions were infiltrating carcinomas [invasive ductal carcinomas (n = 29), invasive lobular carcinomas (n = 2), mixed carcinomas (n = 2), papillary carcinoma (n = 1), and malignant melanoma (n = 2)] and locally malignant phyllodes tumor (n = 1). Benign lesions included fibroadenomas (n = 7), fibrocystic lesions (n = 2), periductal mastitis (n = 2), breast abscess (n = 1), granulomatous mastitis (n = 1), benign fibrolipomatous proliferation (n = 1), lipoma (n = 1), and intramammary lymph node (n = 1). Of note, three patients had double bilateral breast pathologies – two of them had invasive ductal carcinoma (IDC) as well as fibroadenoma and the other patient had invasive lobular carcinoma (ILC) and contralateral intramammary lymph node.

Mammography findings

Analysis of the morphological findings obtained by MX and their comparison with histopathological diagnoses are illustrated in [Table 1].
Table 1: Conventional mammographic findings in patients with breast massesa

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Dual-energy contrast-enhanced mammographic findings

By analysing CEDM images, we found that out of a total 53 breast lesions 47 (88.67%) lesions were enhanced after contrast media administration and six (11.3%) lesions were not enhanced. Out of the enhanced breast lesions, 38 (80.85%) had mass-like enhancement associated with satellite foci in 11 (23.4%) patients, 17 (36.1%) of them enhanced homogeneously, with one having homogenous regular ring enhancement, and 21 (44.6%) of them enhanced heterogeneously. Regarding the degree of enhancement, 37 (78.7%) lesions showed intense enhancement, and 10 (21.2%) lesions showed faint enhancement.

Non-mass-like enhancement was identified in nice (19.1%) breast lesions – six (12.7%) of them were regional and three (6.3%) were segmental in distribution. The enhancement was intense in seven (14.89%) and faint in two (4.2%). The contrast-enhanced mammography (CEM) findings of different breast masses are summarized in [Table 2].
Table 2: Contrast-enhanced mammographic findings in patients with breast masses

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We summarized the numbers and percentages of breast lesions following the BIRADS assessment scale in a pie chart [Figure 8].

Analysis of all previous data revealed that the calculated sensitivity, specificity, and total accuracy of dual-energy contrast-enhanced MX were 83.3, 68.7, and 79.2%, whereas the positive predictive value and negative predictive value were 86 and 64.7%, respectively.

  Discussion Top

Breast cancer is the most common female neoplasm (31% of tumors in females) and the second-leading cause of death among American women [7].

We used dual-energy contrast-enhanced MX subtraction technique on 50 patients with different breast lesions. Our results are in agreement with the study by Jochelson et al. [8], who showed that dual-energy CEDM allowed full compression during imaging, which increased the morphological definition of the lesion.

The present study was a prospective study where 50 women with breast lesions were evaluated by dual-energy CEDM. Twenty-one (42%) patients had multiple unilateral breast lesions, and 10 patients had bilateral breast lesions (20%) (three patients had double pathology). Final diagnoses of the breast lesions achieved by histopathology revealed 37 (69.8%) malignant lesions and 16 (30.1%) benign lesions.

All patients in our study were subjected to conventional digital MX followed by CEDM evaluation. For each lesion, mammographic abnormalities as well as enhancement pattern were evaluated. We aimed at assessing the ability of this modality to characterize benign and malignant breast masses and evaluate whether they can upgrade or downgrade the BIRADS category of such lesions to provide guidance for proper management.

Our study assessed the applications and possible indications of CEDM and its impact on characterization of breast lesions. We applied dual-energy CEDM technique on 50 patients with 53 lesions. We found that 47 (88.67%) lesions were enhanced after contrast media administration, and six (11.3%) lesions were not enhanced. Regarding the degree of enhancement, 37 (78.7%) lesions showed intense enhancement, and 10 (21.2%) lesions showed faint enhancement.

Out of the diagnosed malignant masses by CEDM in our study, 12 (22.6%) showed homogenous enhancement, and 27 (50.94%) showed heterogeneous enhancement. Homogenous enhancement was faint in only one mass; however, 11 malignant masses showed dense homogenous enhancement. On the other hand, out of the 16 diagnosed benign masses by CEM, six (11.3%) showed no enhancement, and eight (15%) showed faint homogenous enhancement.

These results are in agreement with several previous studies [3],[8]. The first was a feasibility study performed on 26 patients by Lewin et al. [3], where 13 had invasive cancers – 11 of these tumors enhanced strongly, one enhanced moderately, and one enhanced weakly. The duct in one patient with ductal carcinoma in situ was weakly enhancing. As for the remaining 12 patients, benign tissue enhanced diffusely in two and weakly and focally in another two. These results indicate that the technique is feasible and worthy of further study. Their study, which was based on the dual-energy method, showed enhancement in 92% of the malignant lesions and in 16.6% of the benign lesions.

In addition, Jochelson et al. [8] reported a similar technique to the one used in our study. Both breasts were examined in two projections after contrast administration using low-energy and high-energy acquisitions. Their analysis included 52 patients with 47 invasive ductal carcinomas, three infiltrating lobular carcinomas, and two cases of ductal carcinoma in situ, including one with an invasive component. conventional mammography detected 42/52 (81%) index cancers, and CESM visualized 14/25 (56%) additional ipsilateral malignant foci.

After comparing lesions categorized by the BIRADS scale on MX and CEDM with histopathological and surgical findings, we found that out of the 37 diagnosed malignant lesions 31 were true positive (26 IDC, two ILC, one mixed carcinoma, one papillary carcinoma, and one was a phyllodes tumor) and five were false positive (four inflammatory and one fibroadenoma). On the other hand, of the 16 patients with benign lesions determined by contrast-enhanced spectral mammography (CESM) in preoperative women, eight were true negative (four fibroadenomas, one fibrocystic disease, one fibroadenosis, one lipoma, and one benign fibrolipomatous proliferation) and six were false negative (two IDC, two malignant melanoma, one mixed lobular, and ductal carcinoma and recurrence of IDC).

Our review of results confirms the diagnostic accuracy of dual-energy CEDM in detecting breast carcinoma and shows clear potential of including CEDM to improve diagnosis of breast cancer. As our inclusion criteria were limited to women with suspicious breast lesions, our results showed increase in sensitivity of CEDM (83.3%) compared with MX alone and/or MX interpreted with US. Most of the previously published studies on CEDM, for example, Dromain and Balleyguier [6]and Diekmann et al. [9] have stated that the increase in sensitivity of cancer detection with CEDM is highly pronounced in suspicious breast lesions.

CEDM allowed a gain for the negative predictive value with a reduction in false negatives (positive predictive value was 86% and negative predictive value was 57%). A dual-energy CEDM study was performed by Dromain and Balleyguier [6] on 120 women with 142 suspect findings on MX and/or US; their results from pathology studies and follow-up identified 62 benign and 80 malignant lesions. Sensitivity was higher for MX + CEDM compared with MX (93 vs. 78%) with no loss in specificity. The lesion size was closer to the histological size for CEDM. All 23 multifocal lesions were correctly detected by MX + CEDM compared with 16 and 15 lesions by MX and US, respectively.

The quality of interpretation of the contrast-enhanced images still diverges markedly between individual readers, which emphasizes that the technique investigated is new, and established standards for interpretation have yet to be developed. An important next step will be to create a more objective basis for interpreting contrast MX and to establish uniform standards for interpretation [10].

The present study hints that CEDM could be of particular interest for assessing the local extent of the disease. In addition, our study has shown that CEDM allowed accurate detection of multifocal breast cancers in some cases (21 cases). Even if slightly higher than that of MX alone, the specificity of CEDM was not optimal, and some benign lesions could depict a significant enhancement such as inflammatory lesions (four patients), some benign tumours such as fibroadenomas (one case), and phyllodes tumor (one case).

The manual injection of contrast media because of unavailability of an automatic injector was a limitation in our study. Therefore, the optimal injection rate was not achieved in some patients.

  Conclusion Top

Using CEDM with dual-energy contrast technique in addition to conventional MX allowed comprehensive evaluation and improved detection and characterization of breast lesions, especially breast carcinoma, and assessment of the local extent of disease. It allowed accurate detection of multifocal breast cancer and double breast pathology, and was proved to be useful for identifying occult lesions in the mammographic dense breast and clarification of equivocal lesions on conventional imaging.

CEDM can be a useful adjunct to diagnostic MX; it is a promising, highly sensitive, problem-solving, and staging tool.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Diekmann F, Diekmann S, Jeunehomme F. Digital mammography using iodine-based contrast media: initial clinical experience with dynamic contrast medium enhancement. Invest Radiol 2005; 40:397–404.  Back to cited text no. 5
Dromain C, Balleyguier C. Contrast-enhanced digital mammography. In: Bick U, Diekmann F, editors. Digital mammography. Heidelberg, Berlin: Springer-Verlag; 2010. pp. 187–198.  Back to cited text no. 6
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Jochelson MS, Dershaw DD, Sung JS. 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; 266:743–751.  Back to cited text no. 8
Diekmann F, Freyer M, Diekmann S. Evaluation of contrast-enhanced digital mammography. Eur J Radiol 2011; 78:112–121.  Back to cited text no. 9
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2]


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