Quantifying lesion enhancement on contrast-enhanced mammography: a review of published data.

AIM: To review and discuss the current published data on FUNCTIONAL DATA DERIVED FROM contrast-enhanced spectral mammography (CESM) for investigation of breast lesions. MATERIALS AND METHODS: Literature searches were conducted in MEDLINE and PUBMED. Due to the novel nature of CESM and sparsity of published literature pertaining to associated functional data, the Medical Subject Headings (MeSH) used were intentionally broad. RESULTS: After inclusion and exclusion criteria, 23 papers were included; 13 pertained to assessment of intensity or pattern of lesion enhancement, and 10 considered textural analysis for lesion assessment, including those using computer-aided detection (CAD) software. Meta-analysis of data was not possible due to heterogeneity of methodology. CONCLUSIONS: There is consistent evidence that benign lesions tend to demonstrate different enhancement characteristics to cancers, with benign lesions tending to demonstrate weaker, homogeneous contrast medium uptake. Limited evidence suggests malignant lesions exhibit "wash-out" or decreasing pattern of enhancement, and benign lesions a progressively enhancing one. The application of textural analysis and radiomics to CESM images shows promising results for differentiating benign and malignant lesions, with potential to predict immunohistological features. A large-scale multicentre study, ideally using multivendor CESM equipment, will be needed to confirm this.

Contrast-enhanced spectral mammography (CESM).

Contrast-enhanced spectral mammography (CESM) is a valuable tool in the diagnosis and staging of primary breast cancer. It combines an iodinated contrast agent with conventional mammography to improve diagnostic accuracy, particularly in women with denser parenchymal background patterns. This review describes the CESM technique, reviews performance compared to conventional mammography and magnetic resonance imaging, assesses its role in the diagnosis and staging of primary breast cancer, and investigates its potential as a screening tool.

Contrast-enhanced spectral mammography improves diagnostic accuracy in the symptomatic setting.

AIM: To assess the diagnostic accuracy of contrast-enhanced spectral mammography (CESM), and gauge its "added value" in the symptomatic setting. MATERIALS AND METHODS: A retrospective multi-reader review of 100 consecutive CESM examinations was performed. Anonymised low-energy (LE) images were reviewed and given a score for malignancy. At least 3 weeks later, the entire examination (LE and recombined images) was reviewed. Histopathology data were obtained for all cases. Differences in performance were assessed using receiver operator characteristic (ROC) analysis. Sensitivity, specificity, and lesion size (versus MRI or histopathology) differences were calculated. RESULTS: Seventy-three percent of cases were malignant at final histology, 27% were benign following standard triple assessment. ROC analysis showed improved overall performance of CESM over LE alone, with area under the curve of 0.93 versus 0.83 (p<0.025). CESM showed increased sensitivity (95% versus 84%, p<0.025) and specificity (81% versus 63%, p<0.025) compared to LE alone, with all five readers showing improved accuracy. Tumour size estimation at CESM was significantly more accurate than LE alone, the latter tending to undersize lesions. In 75% of cases, CESM was deemed a useful or significant aid to diagnosis. CONCLUSION: CESM provides immediately available, clinically useful information in the symptomatic clinic in patients with suspicious palpable abnormalities. Radiologist sensitivity, specificity, and size accuracy for breast cancer detection and staging are all improved using CESM as the primary mammographic investigation.

CT staging for breast cancer patients with poor prognostic tumours.

The aim of this study was to assess the value of computed tomography (CT) staging of the chest, abdomen and pelvis in patients with poor prognostic tumours and no symptoms of metastatic disease in those who have undergone primary surgical management for the treatment of breast cancer. Patients who had primary operable invasive breast cancer treated by surgery over a 2-year period were retrospectively identified. Pathological data from the surgical resection were used to calculate the Nottingham Prognostic Index. Patients with no symptoms of distant metastases who underwent CT staging of the chest, abdomen and pelvis as a result of being placed in the poor prognostic group were identified. The presence and sites of metastatic disease or any indeterminate finding were documented. Additional investigations generated as a result of the staging CT and the outcome were also recorded. Sixty-seven patients (80%) in the poor prognostic group underwent a staging CT. Forty-seven patients (70%) had no signs of metastatic disease on the staging CT. Two patients (3%) were diagnosed with metastatic disease, on the basis of the initial CT scan. Eighteen patients (27%) had an indeterminate finding requiring further investigation, generating 21 additional imaging tests - following this only one additional patient was diagnosed with metastatic disease. Seventeen patients with an initially indeterminate finding did not have metastatic disease, giving a false-positive rate of 25%. In total, three patients (4%) had a final diagnosis of metastatic disease. The routine use of CT staging in patients with no symptoms of distant metastases with primary operable breast cancer even when in a poor prognostic group is of limited value, with a low pick-up rate of metastatic disease and considerable risk of false-positive findings.

Frequency and patterns of metastatic disease in locally advanced inflammatory and non-inflammatory breast cancer.

AIMS: To determine the frequency and pattern of metastatic disease as detected by staging computed tomography in patients presenting with locally advanced primary breast cancer, comparing non-inflammatory and inflammatory subtypes. MATERIALS AND METHODS: Patients who underwent staging computed tomography for locally advanced breast cancer were identified from the hospital's computerised radiology system. The computed tomography scans, breast imaging and pathology were reviewed. RESULTS: Over a 29 month period, 97 patients underwent staging computed tomography for locally advanced primary breast cancer. Sixteen patients (16%) were found to have metastatic disease at presentation. Thirty-eight patients (39%) presented with the inflammatory subtype and 59 patients (61%) with the non-inflammatory subtype. Metastases were significantly more likely in patients with the inflammatory subtype, with 10 patients (26%) having metastases at presentation compared with six patients (10%) with the non-inflammatory subtype (P=0.034). Metastases to the lung and the pleura were the most commonly encountered sites, with pleural-based metastases more likely in patients with the inflammatory subtype (P=0.05). CONCLUSION: Routine computed tomography staging of patients with locally advanced breast cancer is worthwhile with the inflammatory subtype of locally advanced disease having the higher risk of metastatic disease at presentation. Pleural-based metastatic disease is more likely in patients with the inflammatory subtype.

Vacuum-assisted excision of breast lesions of uncertain malignant potential (B3) - an alternative to surgery in selected cases.

To assess whether vacuum-assisted excision (VAE) is a safe alternative to surgery in the treatment of breast lesions of uncertain malignant potential (B3) in which no atypia is present on needle core biopsy (NCB). Forty two VAE procedures were performed for B3 lesions. Twenty four (57%) were papillary lesions. Eighteen (43%) were radial scars. Two patients (4.7%) were upgraded to carcinoma at VAE. Two patients with papillary lesions went on to develop cancer in the same breast (at 24 and 41 months post VAE). No cancer developed in the radial scar group. Eight patients (19%) had surgery - four for carcinoma, two for radial scars missed at VAE excision and two for symptomatic papillomatosis. Follow-up mammography after VAE of radial scars often showed residual distortion. VAE can be a safe alternative to surgery in the treatment of B3 lesions without atypia, providing thorough multidisciplinary discussion has taken place.