1. All that Glitters: How to start a contrast enhanced mammography program
Caitlin Ward, Resident Physician, MSc, MD
Anat Kornecki, Associate Professor, Women’s imaging, MD
Western University, London Ontario
St Joseph’s Healthcare, London Ontario
London Health Sciences Centre, London Ontario

2. Disclosure of conflict of interest
Presenter Disclosure Speaker Name: Caitlin Ward I have no relationships with commercial interests or conflicts of interest to disclose

3. Background
Contrast enhanced spectral mammography (CESM) is a relatively new imaging technique
Made possible by the advent of digital mammography
Developed in the early 2000s and refined and validated over the past decade
Combines conventional digital diagnostic mammography with the administration of iodinated
Administration of iodinated contrast increases the ability to detect malignant breast lesions as a result of the increased neoangiogenesis present in malignant tissue

4. CESM uses
CESM is not currently a part of the BiRADS breast assessment program
There is no BiRADS lexicon for use in CESM, the mammography and MRI lexicon and assessment categories are applied
CESM is therefore currently used as an adjunct breast imaging method in the “post screening” population

5. When is CESM helpful?
CESM is primarily used as a problem solving tool:
For assessing mammographically equivocal lesions
To assess mammographically suspicious lesions with no ultrasound correlate
To reassure benignity in BiRADS 3 lesions and/or avoidance of biopsy
It can also be used as part of breast cancer staging:
Detection of concurrent ipsilateral cancers/multifocality/multicentricity
Suspicion of axillary lymph node involvement
It is an alternative method of assessing for neoangiogenesis and increased probability of malignancy in patients for whom MRI is contraindicated or unavailable:
Claustrophobia
Contraindication to gadolinium
Ferromagnetic foreign body

6. Technique
Current CESM uses a dual energy technique, taking advantage of the K-edge of iodine (33.2 keV).
A copper filter is used to tailor x-rays to a spectrum compatible with the K-edge of iodine
Iodinated contrast is injected at a dose of 1.5 ml/kg body weight and a rate of 3 ml/s
Image acquisition begins at 2 minutes post contrast administration
Two image sets are acquired in routine mammographic views (MLO and CC) of each breast
Low energy (standard digital mammogram) at kVp
High energy at kVp
Software recombination generates a set of low energy routine mammographic views and views with background breast tissue subtracted, demonstrating only contrast enhancement
Dromain et al 2009

7. CESM performance
Multiple studies have demonstrated that CESM has a specificity similar to conventional digital mammography:
56+ %
Non-malignant lesions may also enhance, accounting for low specificity
Fibroadenoma
Papilloma
Radial scar
Comparable sensitivity to MRI (no significant difference in multiple studies):
93 – 98%%
Dromain et al 2011, Fallenberg et al 2014, Lee-Felker et al 2017, Tagliafico et al 2016

8. Other CESM advantages Increased patient convenience:
Can be booked same day as assessment mammogram and ultrasound, preventing second appointment
Short appointment times:
Approximately 15 minute exam time
Shorter time to complete assessment
May be completed in a single day
Since it can be done same day, full assessment can be completed by a single radiologist
Increased patient comfort in comparison to MRI
Due to positioning, exam time, shorter breast compression time
Avoidance of gadolinium usage (lifetime gadolinium accumulation)
As the second set of images acquired are high dose, relatively low increase in overall glandular dose:
x conventional digital mammography
More cost effective than MRI

9. Disadvantages/shortcomings of CESM
Increased radiation dose
Currently no method of performing biopsy under CESM guidance, although this is under development in research phases
In comparison to MRI, field of view is limited and axillae and deep chest wall not adequately assessed for staging purposes
Currently no BiRADS lexicon

10. How to implement a CESM program
Hardware/software requirements
New equipment
Personnel training
Safety protocols
Scheduling
Interpretation

11. Hardware/Software requirements and equipment
GE Healthcare SenoBrightTM system
Dual energy acquisition
Addition of a copper filter
Calculation algorithm for production of recombined images
Contrast power-injector to achieve adequate rate of injection and optimal tissue contrast

12. Our contrast mammography room with control panel

13. Personnel training Patient positioning:
Efficiency and consistency necessary
Timing is of crucial importance in image acquisition as peak enhancement occurs between 5-7 minutes, with washout after 10 minutes
Technician training
How to insert an IV catheter
Use of a power injector

14. Development of protocols
Many protocols were “borrowed“ from the CT program at our institution:
Consent for contrast administration
Safety protocols for contrast reactions
Calculation of iodinated contrast dose
Exam protocols for contrast administration and timing of image acquisition

15. Calculation of contrast dose

16. Scheduling
Troubleshooting was required in the early days of the program to determine optimal scheduling, including:
Length of appointment time
Staffing requirements
Number of staff
Training requirements
Physician presence
Required number of add-on appointments per day

17. Interpretation Phyician training
Breast imagers involved in interpretation of CESM studies completed a CME course on CESM interpretation
Training and site visits from GE Healthcare and with the Gustav Roussy Centre in Paris, France
BiRADS
As no lexicon currently exists, the lexicons develped for digital mammography and MRI are used as appropriate
Report generation
CESM exams are reported in conjunction with ultrasound and digital mammography studies performed as part of the same assessment

18. Case examples

19. Case 1: Invasive mammary carcinoma with lobular features
Distortion within the right lower outer quadrant on screening mammogram: a,b. Right CC and MLO views show distortion. c,d. Right CC and MLO CESM views show avid enhancement of the distortion, suspicious for malignancy.

20. Case 2: Abscess
New palpable abnormality. a,b. Right CC and LM views show a 2.5 cm ill definited mass in the upper outer quadrant. c,d. Right CC and LM CESM views show avid peripheral enhancement with multiple surrounding smaller enhancing masses.

21. Case 2: Abscess ultrasound images
New palpable abnormality. e,f. Ultrasound with (e) and without (f) colour Doppler demonstrate a complicated cyst.

22. Case 3: Phylloides tumour
Palpable left upper outer quadrant lump with rapid increase in size. a,b. Left XCCL and MLO views show a heterogeneous mass in the upper outer quadrant. c,d. Left XCCL and MLO CESM views show heterogeneous nodular enhancement.

23. Case 3: Phylloides tumour ultrasound image
Palpable left upper outer quadrant lump with rapid increase in size. e. Ultrasound shows a mixed solid and cystic mass.

24. Case 4: Inflammatory cyst
Incidental finding on work up for a contralateral asymmetry. a,b. Left CC and MLO views show a well circumscribed mass in the upper outer quadrant. c,d. Left CC and MLO CESM views show peripheral enhancement and central lucency.

25. Case 5: Satellite lesions in invasive mammary carcinoma
Palpable lump in left upper outer quadrant with scattered background parenchyma. a,b. Left CC and MLO views show an ill-defined density with associated calcifications. c,d. Left CC and MLO CESM views show avid enhancement of a 3 cm mass with multiple additional enhancing satellite lesions.

26. Case 6: Benign cysts
Multiple asymmetries within the right breast on screening mammogram: a,b. Right CC and MLO views show asymmetries. c,d. Right CC and MLO CESM views no enhancement, supportive of benignity.

27. Conclusion
Contrast enhanced mammography has been a valuable addition to the breast imaging practice at our institution
Relatively smooth implementation with many protocols borrowed from our CT practice
Improved patient care with decreased time to work up completion and increased convenience

28. References
Chou, C. P., Lewin, J. M., Chiang, C. L., Hung, B. H., Yang, T. L., Huang, J. S., Liao, J. B. & Pan, H. B Clinical evaluation of contrast-enhanced digital mammography and contrast enhanced tomosynthesis--Comparison to contrast-enhanced breast MRI. Eur J Radiol 84: doi: /j.ejrad
Dromain, C., Balleyguier, C., Adler, G., Garbay, J. R. & Delaloge, S Contrast-enhanced digital mammography. Eur J Radiol 69: doi: /j.ejrad
Dromain, C., Thibault, F., Muller, S., Rimareix, F., Delaloge, S., Tardivon, A. & Balleyguier, C Dual-energy contrast-enhanced digital mammography: initial clinical results. Eur Radiol 21: doi: /s y.
Fallenber, E.M., Dromain, C., Engelken, F., Krohn, M., Sing, J.M., Ingold-Heppner, B., Winzer, K.J., Bick, U., Renz, D.M Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size. Breast 24: , doi: /s
Fallenberg, E. M., Schmitzberger, F. F., Amer, H., Ingold-Heppner, B., Balleyguier, C., Diekmann, F., Engelken, F., Mann, R. M., Renz, D. M., Bick, U., Hamm, B. & Dromain, C Contrast-enhanced spectral mammography vs. mammography and MRI - clinical performance in a multi-reader evaluation. Eur Radiol 27: doi: /s
Lee-Felker, S. A., Tekchandani, L., Thomas, M., Gupta, E., Andrews-Tang, D., Roth, A., Sayre, J. & Rahbar, G Newly Diagnosed Breast Cancer: Comparison of Contrast-enhanced Spectral Mammography and Breast MR Imaging in the Evaluation of Extent of Disease. Radiology 285: doi: /radiol
Tagliafico, A. S., Bignotti, B., Rossi, F., Signori, A., Sormani, M. P., Valdora, F., Calabrese, M. & Houssami, N Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis. Breast 28: doi: /j.breast
Tardivel, A. M., Balleyguier, C., Dunant, A., Delaloge, S., Mazouni, C., Mathieu, M. C. & Dromain, C Added Value of Contrast-Enhanced Spectral Mammography in Postscreening Assessment. Breast J 22: doi: /tbj
 Thibault, F., Balleyguier, C., Tardivon, A. & Dromain, C Contrast enhanced spectral mammography: better than MRI?. Eur J Radiol 81 Suppl 1: S doi: /s x(12)