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Contrast-Enhanced Spectral Mammography (CESM) is a recently introduced mammographic method with characteristics particularly suitable for breast cancer radiomic analysis. This work aims to evaluate radiomic features for predicting histological outcome and two cancer molecular subtypes, namely Human Epidermal growth factor Receptor 2 (HER2)-positive and triple-negative. From 52 patients, 68 lesions were identified and confirmed on histological examination. Radiomic analysis was performed on regions of interest (ROIs) selected from both low-energy (LE) and ReCombined (RC) CESM images. Fourteen statistical features were extracted from each ROI. Expression of estrogen receptor (ER) was significantly correlated with variation coefficient and variation range calculated on both LE and RC images; progesterone receptor (PR) with skewness index calculated on LE images; and Ki67 with variation coefficient, variation range, entropy and relative smoothness indices calculated on RC images. HER2 was significantly associated with relative smoothness calculated on LE images, and grading tumor with variation coefficient, entropy and relative smoothness calculated on RC images. Encouraging results for differentiation between ER+/ER−, PR+/PR−, HER2+/HER2−, Ki67+/Ki67−, High-Grade/Low-Grade and TN/NTN were obtained. Specifically, the highest performances were obtained for discriminating HER2+/HER2− (90.87%), ER+/ER− (83.79%) and Ki67+/Ki67− (84.80%). Our results suggest an interesting role for radiomics in CESM to predict histological outcomes and particular tumors’ molecular subtype.

IntroductionBreast cancer still represents the leading tumor among women and the incidence of the disease is rising all over the world (1, 2). The risk of developing breast cancer is related to a number of factors including the events of reproductive life and lifestyle factors that modify endogenous levels of sex hormones. Diet has been also found to play an important role in the etiology of breast cancer.Mammography represents the most used modality for breast cancer screening, with mortality reduction of 30-40% in screened population (3, 4). However, its sensitivity is decreased in young women with radiologically dense breast (5). Another limitation of planar mammography is represented by the two-dimensional visualization of a three-dimensional volumetric structure such as the breast, with a consequent superimposition of tissue. These limitations are partially solved by the full-field digital mammography (FFDM), with its improved dynamic range, tissue contrast and post-processing, and by the digital breast tomosynthesis (DBT), which partially addresses the two-dimensional breast representation of planar mammography (4). Dual-energy contrast enhanced digital mammography represents a novel technique and has a reported sensitivity of 93% versus 78% of conventional mammography alone (6).With the recent advances in technology, US and MRI allow to delineate occult malignancy in women with dense breast tissue, especially in case of high risk patients (5,7,8).Recently, nuclear medicine imaging technology has been introduced in the field of breast cancer with the development of positron emission tomography (PET), PET- Aim. To compare the diagnostic accuracy of fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) in patients with USdetected breast lesions.Patients and methods. KEY WORDS: Breast -Fine-needle aspiration cytology -Core needle biopsy -FNAC -CNB.