Mamografia cu substanta de

contrast

Anca Ciurea
Universitatea de Medicina si Farmacie
“I. Hatieganu” Cluj-Napoca
 Mamografia
 Investigatie pentru paciente
simptomatice > 40 ani
 Screening cancer mamar

Avantaje
- ieftina
- tehnica disponibila pe scara largareadily available
technique
Dezavantaje
- Sensibilitate redusa (femei tinere)
Mamografia cu substanţă de contrast

 Imbunătăţeşte vizibilitatea leziunilor

- agent de contrast iodat + tehnica
mamografiei standard

 Vizualizează iodofilia datorată

neovascularizaţiei leziunilor mamare
maligne (în manieră similară examinării
IRM cu substanţă de contrast)

 Furnizează elemente de imagistică

funcţională
11/11/2020
Clinical Radiology 2018 73, 715-723DOI: (10.1016/j.crad.2018.05.005) Copyright © 2018 The Royal College of Radiologists
CEM (Contrast Enhanced Mammography)

 TCEM (Temporal Contrast Enhanced

Mammography) (cu substracţie
temporală)

 CESM (Contrast Enhanced Spectral

Mammography)
Mamografia cu substanţă de contrast

 Administrare intravenoasă de
substanţă de contrast iodată
 doza – aprox. 1.5 ml/kg corp (~100
ml)
 injector automat
 rata de infuzie – 3 ml/s (33 sec.)
TCEM
 Sânul este comprimat
 Imagine nativă (masca) a sân, într+o
singură incidenţă

 Administrarea SC se face în timp ce sânul

rămâne comprimat
 Imagini succesive la 1 min (pe o durată de
3-5 min)

 Imaginea pre-contrast este subtrasă din

imaginile post-contrast
M.B.I. Lobbes et al. Contrast enhanced mammography: Techniques, current results, and potential
indications. Clinical Radiology 68 (2013) 935e944
TCEM
 Dezvoltată pentru evaluarea iodofiliei dinamice (similar
curbei de captare din IRM)

Jong RA, Yaffe MJ, Skarpathiotakis M, et al. Contrast-enhanced digital

mammography: initial clinical experience. Radiology. 2003 Sep;228(3):842-50
 Carcinom (a+c) vs
Papilom (b+d)

Jong RA, Yaffe MJ, Skarpathiotakis M, et al. Contrast-enhanced digital

mammography: initial clinical experience. Radiology. 2003 Sep;228(3):842-50
TCEM

 evaluarea iodofiliei temporale (dinamica leziunii) nu este

totuşi similara celei din IRM mamară

- efectul cauzat de compresiunea sânului în timpul

administrării contrastului

- porţiunea precoce a curbei de captare nu este

surprinsă în mod corespunzător (administrarea SC
durează mai mult în mamo cu contrast comparativ cu
IRM mamară – volum mai mare de SC)
CESM
 exam începe cu administrarea iv de SC
 2 minute de la ÎNCEPEREA injectării se
achiziţionează un set de imagini cu energie
joasă şi energie înaltă, în succesiune rapidă
 sânul este comprimat câteva secunde
pentru fiecare incidenţă (craniocaudal or
mediolateral oblique)
 toate imaginile sunt achiziţionate folosind
grila antidifuzoare
M.B.I. Lobbes et al. Contrast enhanced mammography: Techniques, current results, and potential
indications. Clinical Radiology 68 (2013) 935e944
CESM

 Imaginile cu energie joasă

- ţinta (anoda): Mo/Rh
- filtre: Mo/Rh

 kilovoltaj (kVp) între 26-31 kVp

CESM
 k-edge of iodine is at 33.2 keV
 the entire x-ray spectrum used for LE
images is below the k-edge of the I
 X-rays not absorbed by iodine
 LE images provide maximum soft-
tissue contrast =“regular”
mammographic image
 LE images – not suitable for the
visualization of iodine
CESM
 To visualize iodine - x-rays beyond the k-edge of
iodine
 Structures that contain the iodine contrast agent
attenuate much more.
 High-energy images
- target: Mo
- multilayer filter: Copper

 peak kilovoltage values ranging from 45-49 kVp.

As a result, the x-ray spectrum is now above the k-edge
of iodine. This high energy image contains information
on lesion enhancement caused by the administration
of iodine-based contrast, but cannot be used for
diagnostic purposes on its own.
High energy images – not suitable for diagnosis purposes
CESM
 recombined images – logarithmic subtraction of
LE and HE images
 image that displays the areas of contrast
enhancement, while cancelling out anatomic
noise
CESM

LE images Recombined images

 CESM – advantages
 the low-energy component – equivalent to
a conventional mammogram
 the low-energy component – acquired using
an X-ray spectrum that is identical to a
FFDM
 the image resembles a conventional
mammogram
 the only difference – iodinated contrast
agent is present in the breast at the time of
image acquisition.

Fallenberg EM, Dromain C, Diekmann F, et al. Contrast-enhanced spectral mammography: does mammography provide
additional clinical benefits or can some radiation exposure be avoided? Breast Cancer Res Treat 2014;146:371e81.
Francescone MA, Jochelson MS, Dershaw DD, et al. Low energy mammogram obtained in contrast-enhanced digital
mammography (CEDM) is comparable to routine full-field digital mammography (FFDM). Eur J Radiol 2014;83:1350e5.
 CESM – advantages

 Comparison FFDM with LE CESM

- quality criteria defined by the European
Reference Organisation for Quality Assured
Breast Screening and Diagnostic Services
(EUREF)

- the low-energy component of the CESM

examination was non-inferior

Lalji UC, Jeukens CRLPN, Houben I, et al. Evaluation of low- energy contrast-enhanced spectral mammography
images by comparing them to full-field digital mammography using EUREF image quality criteria. Eur Radiol
2015;25:2813e20.
 CESM – advantages

 FFDM and LE CESM equivalent

- technical parameters comparable
- same ability to detect, measure,
and characterise lesions (including
microcalcifications)

Francescone MA, Jochelson MS, Dershaw DD, et al. Low energy mammogram obtained in contrast-enhanced digital
mammography (CEDM) is comparable to routine full-field digital mammography (FFDM). Eur J Radiol
2014;83:1350e5.
CEM – disadvantages
 Contrast media
- risk of causing CIN (AKI) has to be
established prior to every CEM examination
- risk of developing CIN – renal function
- anaphylactic reactions

 TCEM – Acquisition 1 breast, one view

- contralateral breast – another CM adm

 CM adverse reactions hamper the use of

CEM outside of the hospital setting
 CEM – advantages
 Contrast media
- AKI – 1-2%
- UK audit – no AKI in 3,590 outpatients
- in patients at higher risk (known impairment of
renal function) – no difference in serum creatinine
levels was demonstrated before and after contrast
agent administration

 Fit patient/no history/no risk factors

- CEM – performed at the time of examination
Cope LH, Drinkwater KJ, Howlett DC. RCR audit of compliance with UK guidelines for the prevention and
detection of acute kidney injury in adult patients undergoing iodinated contrast media injections for CT.
Clin Radiol 2017;72:1047e52
 CEM – advantages
 Contrast media
- parenchimal backgroud enhancement
- diagnostic difficulty – rare (bilateral, symmetrical
appearance)
- no clear pattern in variation of PBE across the
menstrual cycle

- CEM – timing the examination not so important

- CEM – performed at the time of examination

James JJ, Tennant SL. Contrast-enhanced spectral mammography (CESM). Clinical Radiology
2018;73:715-723.
CEM – disadvantages
 Acquisition time
- longer (TCEM>CESM)
- risk of motion artifacts

 Rim artifact - rind of increased density

at the periphery of the breast due to
scatter radiation
Scatter correction techniques
 CEM – disadvantages
 Radiation dose
- TECM = FFDM (x number of images)
- CESM = 1.2 x FFDM
43% to 81% (within European and UK quality assurance guidelines
for mammography – 3mGy per incidence)
 GE (81%)
- AGD CESM 2.8 mGy vs 1.55 mGy FFDM
 Hologic (43%)
- AGD CESM 3 mGy vs 2.1 mGy FFDM

Jeukens CR, Lalji UC, Meijer E, et al. Radiation exposure of contrast enhanced spectral mammography compared
with full-field digital mammography. Investig Radiol 2014;49:659e65.
James JR, Pavlicek W, Hanson JA, et al. Breast radiation dose with CESM compared with 2D FFDM and 3D
CEM – disadvantages

 No contrast mammography guided

biopsies
Clinical indications
 Local staging of breast cancer - compared with 2D Mx
– sensitivity with >20%
- depicts more multifocal tumors
- size overestimation with 0.3 mm (2.2 mm underest US)
Clinical indications
 Local staging of breast cancer - compared with MRI
- similar sensitivity
- superior specificity

Copyright © 2018 The Royal College of Radiologists Terms and Conditions

Clinical Radiology 2018 73, 715-723DOI: (10.1016/j.crad.2018.05.005)
 Clinical indications
 Preoperative staging

M.B.I. Lobbes et al. Contrast enhanced mammography: Techniques, current results, and potential indications. Clinical Radiology 68
(2013) 935e944
Clinical indications
 Response to chemotherapy

11/11/2020
Clinical Radiology 2018 73, 715-723DOI: (10.1016/j.crad.2018.05.005)
Copyright © 2018 The Royal College of Radiologists Terms and Conditions
 Clinical indications
 Inconclusive
Findings
(neconcludente)

M.B.I. Lobbes et al. Contrast enhanced mammography: Techniques, current results, and potential indications. Clinical Radiology 68
(2013) 935e944
Clinical indications

 Diagnostic in selected patients

(symptomatic/suspicious findings US)

 Screening in risk patients

- more accessible than MRI
- preferred by patients
- less false positive and biopsies
 CESM – false positive/negative
 False positive  False negative
-fibroadenomas - lesion not included on
- papillomas the mammographic field
- hamartomas of view
- intra-mammary - invasive lobular
nodes carcinoma
- fat necrosis - ductal carcinoma
- DCIS with only subtle or
no enhancement on the
recombined images have
been reported
- mucinous carcinomas
Thank you