1. DUAL ENERGY CONTRAST ENHANCED SPECTRAL MAMMOGRAM : AS A PROBLEM SOLVING TOOL IN EQUIVOCAL CASES Abstract ID IRIA-1121

2.  Breast cancer incidence has increased by more than 20%,mortality has increased by 14%(1)  One in four of all cancers in women(1)  Full field digital mammography is well established, cost effective screening modality in detection of breast cancer.

3. Certain limitations -mammography In dense breasts In lesions identified only on one view (for mammogram) In detection of subtle lesions

4. C ase 1 A 48 yr old female with dense breast,

5.  Sensitivity of conventional mammogram  98% for fatty breasts  48% for dense breasts(3)

6. In order to increase sensitivity a newer imaging technique called Contrast enhanced digital mammogram (CEDM) which could demonstrate neovascularization was incorporated into breast imaging.

7. Digital mammogram CEDM

8. Case 2 37 yr old,with dense breast, for routine screening:

10.  After intravenous iodinated contrast injection  A simultaneous pair of high energy and low energy exposures were made for both the craniocaudal and mediolateral oblique view of both breasts  A recombined image was obtained using specific dual energy recombination algorithm. How Dual Energy Contrast Enhanced Mammography Is Performed ?

11. Figure 1, schematic representation of sequence of images acquired

12. GOAL OF OUR STUDY To assess the role of additional CEDM in occult /equivocal findings on digital mammogram Assessing accuracy of CEDM in predicting probability of malignancy

13. WHERE IS CEDM MOST USEFUL?  Identifies occult lesions in dense breast  Demonstrates extent of lesion, ductal extension  Establishes multifocality  Identifies site for histopathology  Serves as complete assessment, eliminating questionable findings to be followed up  Follow up to assess response to treatment

14. Case3 Suspicious microcalcification:

15. Suspicious microcalcification:

16. Case 4 Subtle architectural distortion

18. Is there any role for CEDM in mammography detected malignancy ?

19. case 5 Ductal extension demonstrated on CEMG

21. Case 6 Multifocality shown on CEMG

23. Case 7 True extent

25. Role in cases with multiple lesions ?

26. Case 8 Identifies BIRADS IV lesion among multiple lesions:

27. Case 9 & 10 Proves benign nature

28. In following up response to treatment ?

29. Case 11 Follow up post chemoradiation- shows response

30. OUR STUDY 44 consented patients underwent mammogram(MG) and contrast enhanced mammogram(CEMG) Confidence of presence of lesion on a three point scale Probablity of malignancy as BIRADS was assessed independently by two well qualified radiologists. Histopathology taken as gold standard. Interobserver variation calculated by obtaining kappa value.

32. Area under curve for confidence of presence – observer 1 Mg -0.485 Mg+cemg -0.685 Area under curve for confidence of presence- observer 2 Mg -0.526 Mg+cemg -0.635

33. Area under curve for probablity of malignancy – observer1 Mg 0.718 Mg+cemg=0.812 Area under curve for probablity of malignancy – observer 2 Mg 0.738 Mg+cemg 0.812

34. CONSISTENCY P = 0.000 MEASURMENT OF AGREEMENT KAPPA =0.837 Cross tabulation of contrast enhanced mammogram findings between observer 1 and 2 CEMG(2) CEMG (1) Not seenFaintly seenseentotal Not seen 49.1%00%12.3%511.4% Faintly seen 00%24.5%00%24.5% seen00%12.3%3681.8%3784.1% total49.1%36.8%3784.1%44100%

35. MG (1)MG+CEMG(1)MG(2)MG+CEMG(2) Confidence of presence Sensitivity76.5978597 Specificity20402030 PPV76.5857883 NPV20802975 P value0.8150.0010.6870.009 BIRADSSensitivity74826882 Specificity7080 PPV89939293 NPV44574237 P value0.0120.0000.0070.000 Mammogram versus mammogram + contrast enhanced mammogram for two observers, taking histopathology as gold standard

36. ENCOURAGING CLINICAL RESULTS HAVE BEEN PUBLISHED DURING THE LAST FEW YEARS Contrast-enhanced digital mammography : initial clinical experience Jong RA et al. Radiology 2003; 228:842-850 Dual-energy contrast enhanced digital subtraction mammography : feasibility Lewin JM et al. Radiology 2003; 209;261-268 Digital mammography using iodine-based contrast media : initial clinical experience with dynamic contrast medium enhancement. Diekmann F et al, Invest radiol 2005 Evaluation of tumor angiogenesis of breast carcinoma using Contrast Enhanced Digital Mammography. Dromain C et al, AJR 2006; 187:W528-37. Contrast-enhanced digital mammography ; Clarisse Dromaina, ∗, Corinne Balleyguiera, Ghazal Adlera, Jean Remi Garbayb, Suzette Delalogec European Journal of Radiology 69 (2009) 34–42 Dual-energy contrast-enhanced digital mammography: initial clinical results of a multireader, multicase study. Clarisse Dromain, 1 Fabienne Thibault,2 Felix Diekmann,3 Eva M Fallenberg,3 Roberta A Jong,4 Marcia Koomen,5 R Edward Hendrick,6 Anne Tardivon,2 and Alicia Toledano Breast Cancer Res. 2012; 14(3): R94. Published online Jun 14, 2012. doi: 10.1186/bcr3210 PMCID: PMC3446357Clarisse DromainFabienne ThibaultFelix DiekmannEva M FallenbergRoberta A JongMarcia KoomenR Edward HendrickAnne TardivonAlicia Toledano10.1186/bcr3210

37. TAKE HOME POINTS Contrast enhanced mammogram has definite role  In identifying occult lesions in dense breast  Demonstrates ductal extension  Establishes multifocality  Identifies site for histopathology in case of multiple lesions  Assess response to treatment  Serves as complete assessment tool,eliminating questionable findings to be followed up

38. REFERENCES 1 Golobocon 2012 released on 12 th dec 2013: http://www.iarc.fr/en/media- centre/pr/2013/pdfs/pr223_E.pdf 3Boyd NF, Byng JW, Jong RA, Fishell EK, Little LE, Miller AB, et al. Quantitative classification of mammographic densities and breast cancer risk: Results from the Canadian National Breast Screening Study.J Natl Cancer Inst. 1995; 7.Contrast-enhanced digital mammography Clarisse Dromaina, ∗, Corinne Balleyguiera, Ghazal Adlera, Jean Remi Garbayb, Suzette Delalogec European Journal of Radiology 69 (2009) 34–42 8.Prionas ND, Lindfors KK, Ray S, Huang SY, Beckett LA, Monsky WL,Boone JM: Contrast-enhanced dedicated breast CT: initial clinical experience. Radiology 2010, 256:714-723. 9 Hendrick RE: Radiation doses and cancer risks from breast imaging studies. Radiology 2010, 257:246-253. 10. American College of Radiology: Breast Imaging Reporting and Data System: BI-RADS. 4 edition. Reston, VA: American College of Radiology; 2003.

39. Thank you