Contrast-enhanced mammography for the assessment of screening recalls: a two-centre study

Abstract

Objectives To evaluate the potential of contrast-enhanced mammography (CEM) for reducing the biopsy rate of screening recalls. Methods Recalled women were prospectively enrolled to undergo CEM alongside standard assessment (SA) through additional views, tomosynthesis, and/or ultrasound. Exclusion criteria were symptoms, implants, allergy to contrast agents, renal failure, and pregnancy. SA and CEM were independently evaluated by one of six radiologists, who recommended biopsy or 2-year follow-up. Biopsy rates according to SA or recombined CEM (rCEM) were compared with the McNemar’s test. Diagnostic performance was calculated considering lesions with available final histopathology. Results Between January 2019 and July 2021, 220 women were enrolled, 207 of them (median age 56.6 years) with 225 suspicious findings analysed. Three of 207 patients (1.4%) developed mild self-limiting adverse reactions to iodinated contrast agent. Overall, 135/225 findings were referred for biopsy, 90/225 by both SA and rCEM, 41/225 by SA alone and 4/225 by rCEM alone (2/4 being one DCIS and one invasive carcinoma). The rCEM biopsy rate (94/225, 41.8%, 95% CI 35.5–48.3%) was 16.4% lower (p < 0.001) than the SA biopsy rate (131/225, 58.2%, 95% CI 51.7–64.5%). Considering the 124/135 biopsies with final histopathology (44 benign, 80 malignant), rCEM showed a 93.8% sensitivity (95% CI 86.2–97.3%) and a 65.9% specificity (95% CI 51.1–78.1%), all 5 false negatives being ductal carcinoma in situ detectable as suspicious calcifications on low-energy images. Conclusions Compared to SA, the rCEM-based work-up would have avoided biopsy for 37/225 (16.4%) suspicious findings. Including low-energy images in interpretation provided optimal overall CEM sensitivity. Key Points • The work-up of suspicious findings detected at mammographic breast cancer screening still leads to a high rate of unnecessary biopsies, involving between 2 and 6% of screened women. • In 207 recalled women with 225 suspicious findings, recombined images of contrast-enhanced mammography (CEM) showed a 93.8% sensitivity and a 65.9% specificity, all 5 false negatives being ductal carcinoma in situ detectable on low-energy images as suspicious calcifications. • CEM could represent an easily available one-stop shop option for the morphofunctional assessment of screening recalls, potentially reducing the biopsy rate by 16.4%.

Contrast-enhanced mammography for screening recalls: a problem-solving assessment tool ready for use?

“…Overall, the findings by Cozzi et al [5] confirm results from previous studies that CEM has the potential as a problemsolving tool for the assessment of screening recalls [6]. A practical advantage is the short learning curve as demonstrated by increased diagnostic accuracy even for less experienced radiologists [6].…”

“…In this issue of European Radiology, Cozzi et al [5] present the effect of CEM on biopsy rate in women recalled for assessment after DM screening. The study included 207 women with 225 suspicious findings prospectively enrolled to undergo CEM alongside standard assessment.…”

“…Fibroadenomas and superposition densities have been reported as the most common causes of false positives [6]. DCIS presenting with calcifications may show no or extremely faint associated contrast enhancement on recombined (rCEM) images, but the low-energy images will demonstrate the calcifications and permit a correct diagnosis [5]. In general, CEM only slightly improves the diagnostic accuracy of calcifications and is not of added value compared to DM in guiding surgical decision-making [7].…”

Improving the malignancy prediction of breast cancer based on the integration of radiomics features from dual-view mammography and clinical parameters

“…Digital mammography (DM), which uses a 2D technique, is a widely used tool for detecting breast cancer, and the American Cancer Society has declared that mammography is one of the best approaches to preserving women's health (Lei et al 2019;Wanders et al 2022). However, mammography still has a serious restriction in that the appearance of lesions may be diminished, leading to missed or incorrect diagnosis for relying exclusively on a morphological appraisal of suspicious ndings, which may foster an increase in the positive predictive value (PPV) of work-up examinations (Hui et al 2020;Cozzi et al 2022). Radiomics, which uses quantitative methods that can be more bene cial for diagnosing and de ning benign and malignant breast tumors, was used to overcome these constraints (Erdim et al 2020;Priya et al 2021).…”

Contrast-enhanced mammography-guided biopsy: why, when, and where we need it

“…Notably, the American College of Radiology practice parameters underline how any facility performing breast MRI should provide MRI-guided biopsy whenever needed, or at least cooperate with a referral centre capable of performing it. While a recent study [8] pitching the standard morphological work-up of screening recalls against a CEM-only approach found that rates of CEM-only findings match those observed for MRI, another study [9] had already highlighted how only 31% of CEM-detected findings had a correlate at second-look ultrasound, emphasizing the need of CEM-guided biopsy.…”