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Breast Cancer Diagnosis

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Breast cancer remains a worldwide public health issue and is currently the most common cancer across the globe. About one in twenty women will be diagnosed with breast cancer over the course of their lifetime [1]. In 2020, there were 2.3 million women diagnosed with breast cancer and 685 000 deaths globally [2]. From 2013 to 2018, the death rate went down by 1% per year. This decrease is believed to be the result of finding breast cancer earlier through screening and increased awareness, as well as finding better treatments [3].


Two imaging techniques, mammography (MG) and ultrasound (US) [4] are currently used as a routine clinical practice for breast imaging. Mammography is the gold standard imaging technique for breast cancer screening, follow-up or in case of clinical signs. [5-9] However, in some cases, mammography has limited sensitivity such as for the study of high-density breasts [10,11], which requires additional examinations such as MRI [12-15]. In recent years, new imaging techniques have been developed, which are less costly and more accessible than MRI, including contrast-enhanced spectral mammography (CESM) [16]. This technique improves the sensitivity and the specificity of breast cancer detection as it provides higher contrast and better lesion delineation than mammography alone. [16-19]


CESM is a recent development of mammography combining X-ray imaging of the breast and the use of intravenous iodinated contrast agents. CESM is performed by using standard mammography equipment that has been upgraded to include copper filtration and additional software that make the unit capable of performing dual energy imaging [20].


Two minutes before image acquisition, an iodine-based contrast medium is intravenously injected at a standard dose of 1.5 mL/kg and a rate of 2-3 mL/s [21]. Next, at minimum, both breasts are imaged in craniocaudal (CC) and mediolateral oblique (MLO) views. In each step, compression is applied followed by rapid acquisition of low- and high-energy images. Low and high energy images are processed to generate recombined images. After each exposure, compression is released. Images are considered to be of diagnostic value if they are acquired within 10 minutes after contrast material administration.


Typical example of CESM images:

First, a low-energy image is acquired (A, comparable to a standard mammography), immediately followed by the high-energy image (B), which is used in post-processing to create the recombinant image (C), in which a lesion is clearly visible.

figure: Illustration of CESM case [22]

Contrast-Enhanced Mammography - Clinical implementation and standardized reporting

Breast imaging using MRI or Contrast-Enhanced Mammography: Friends or Foes?

Sources and references:

1) Breast Cancer | The Cancer Atlas 2) Breast cancer (who.int) 3) Key Statistics for Breast Cancer | American cancer society 4) Kolb TM, Lichy J, Newhouse JH. Comparison of the performance of screening mammography, physical examination, and breast US and evaluation of factors that influence them: an analysis of 27,825 patient evaluations. Radiology, 2002; 225(1):165-75 5) The Swedish Organised Service Screening Evaluation Group. Reduction in breast cancer mortality from organized service screening with mammography: 1. Further confirmation with extended data. Cancer Epidemiol Biomarkers Prev, 2006; 15(1):45–51 6) Tabar L, Yen MF, Vitak B et al. Mammography service screening and mortality in breast cancer patients: 20-year follow-up before and after introduction of screening. Lancet, 2003; 361(9367):1405–10 7) Otto SJ, Fracheboud J, Looman CWN et al. Initiation of population-based mammography screening in Dutch municipalities and effect on breast-cancer mortality: a systematic review. Lancet, 2003; 361(9367):1411–7 8) Sardanelli F, Fallenberg EM, Clauser P et al. Mammography: an update of the EUSOBI recommendations on information for women. Insights Imaging, 2017; 8(1):11-18 9) Cardoso F, Kyriakides S, Ohno S et al. Early breast cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol, 2019; 30(8):1194-1220 10) Rosenberg RD, Hunt WC, Williamson MR et al. Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage at diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico. Radiology, 1998; 209(2):511–8 11) Emaus MJ, Bakker MF, Peeters PHM et al. MR Imaging as an additional screening modality for the detection of breast cancer in women aged 50-75 years with extremely dense breasts: the DENSE trial study design. Radiology, 2015; 277(2):527-37 12) Fischer U, Kopka L, Grabbe E. Breast carcinoma: effect of preoperative contrast-enhanced MR imaging on the therapeutic approach. Radiology, 1999; 213(3):881–8 13) Liberman L, Morris EA, Kim CM et al. MR imaging findings in the contralateral breast of women with recently diagnosed breast cancer. AJR Am J Roentgenol, 2003; 180(2):333-41 14) Hollingsworth AB, Stough RG, O’Dell CA, Brekke CE. Breast magnetic resonance imaging for preoperative locoregional staging. Am J Surg, 2008; 196(3):389–97 15) Schell AM, Rosenkranz K, Lewis PJ. Role of breast MRI in the preoperative evaluation of patients with newly diagnosed breast cancer. AJR Am J Roentgenol, 2009; 192(5):1438–44 16) Fallenberg EM et al. Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size. Eur Radiol., 2014; 24(1):256–64 17) Dromain C, Balleyguier C, Muller S et al. Evaluation of tumor angiogenesis of breast carcinoma using contrast-enhanced digital mammography. AJR Am J Roentgenol, 2006; 187(5):W528–37 18) Dromain C, Thibault F, Muller S et al. Dual-energy contrast-enhanced digital mammography: initial clinical results. Eur Radiol., 2011; 21(3):565–74 19) Dromain C, Thibault F, Diekmann F et al. Dual-energy contrast-enhanced digital mammography: initial clinical results of a multireader, multicase study. Breast Cancer Res., 2012; 14(3):R94 20) Haute Autorité de Santé: Rapport d’evaluation de l’intérêt de l’angiomammographie double énergie dans la stratégie diagnostique du cancer du sein. 2021 21) Jochelson MS, Lobbes MBI. Contrast-enhanced Mammography: State of the Art. Radiology, 2021; 299(1):36-48 22) Lobbes MBI, Lalji UC, Nelemans PJ et al. The quality of tumor size assessment by contrast-enhanced spectral mammography and the benefit of additional breast MRI. J Cancer, 2015; 6(2):144-50

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P22001401 July 2022