DUAL ENERGY CONTRAST ENHANCED
SPECTRAL MAMMOGRAM : AS A PROBLEM
SOLVING TOOL IN EQUIVOCAL CASES
Abstract ID
IRIA-1121
 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.
Certain limitations -mammography
• In dense breasts
• In lesions identified only on one view (for mammogram)
• In detection of subtle lesions
Case 1
A 48 yr old female with dense breast,
 Sensitivity of conventional mammogram
 98% for fatty breasts
 48% for dense breasts(3)
In order to increase sensitivity a newer imaging
technique called Contrast enhanced digital
mammogram (CEDM) which could demonstrate
neovascularization was incorporated into
breast imaging .
Digital mammogram
CEDM
Case 2
37 yr old ,with dense breast, for routine screening:
Case 2
37 yr old ,with dense breast, for routine screening:
How Dual Energy Contrast Enhanced
Mammography Is Performed ?
 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.
Figure 1 , schematic
representation of sequence of
images acquired
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
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
Case3
Suspicious microcalcification:
Suspicious microcalcification:
Case 4
Subtle architectural distortion
Case 4
Subtle architectural distortion
• Is there any role for CEDM in
mammography detected malignancy ?
case 5
Ductal extension demonstrated on CEMG
case 5
Ductal extension demonstrated on CEMG
Case 6
Multifocality shown on CEMG
Case 6
Multifocality shown on CEMG
Case 7
True extent
Case 7
True extent
• Role in cases with multiple lesions ?
Case 8
Identifies BIRADS IV lesion among multiple lesions:
Case 9 & 10
Proves benign nature
In following up response to treatment ?
Case 11
Follow up post chemoradiation- shows response
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.
Histopathology of study group
Malignant /precancerous
Benign/ inconclusive
ROC Curve
ROC Curve
Source of the Curve
1.0
Source of the Curve
Mg .o1
Mg+cemg 123 observer
1
Reference Line
1.0
0.8
Sensitivity
Sensitivity
0.8
Mg .o2
ce +mg observer 2
Reference Line
0.6
0.4
0.2
0.6
0.4
0.2
0.0
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Diagonal segments are produced by ties.
Area under curve for confidence of
presence – observer 1
Mg -0.485
Mg+cemg -0.685
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Diagonal segments are produced by ties.
Area under curve for confidence of
presence- observer 2
Mg -0.526
Mg+cemg -0.635
ROC Curve
ROC Curve
Source of the Curve
1.0
Source of the Curve
1.0
Mg birads.o2
Mg + cemg
biradsobserver 2
Reference Line
0.8
Sensitivity
Sensitivity
0.8
Mg birads impression.
o1
mg+cemg BIRADS
observer 1
Reference Line
0.6
0.4
0.2
0.6
0.4
0.2
0.0
0.0
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Diagonal segments are produced by ties.
Area under curve for probablity of malignancy –
observer1
Mg 0.718
Mg+cemg=0.812
0.0
0.2
0.4
0.6
0.8
1.0
1 - Specificity
Diagonal segments are produced by ties.
Area under curve for probablity of malignancy –
observer 2
Mg 0.738
Mg+cemg 0.812
CONSISTENCY
Cross tabulation of contrast enhanced mammogram findings between observer 1 and 2
CEMG(2)
CEMG
(1)
Not seen
Faintly seen
seen
Not seen
4
9.1%
0
0%
1
2.3%
5
11.4%
Faintly
seen
0
0%
2
4.5%
0
0%
2
4.5%
seen
0
0%
1
2.3%
36
81.8%
37
84.1%
total
4
9.1%
3
6.8%
37
84.1%
44
100%
P = 0.000
MEASURMENT OF AGREEMENT KAPPA =0.837
total
Mammogram versus mammogram + contrast enhanced mammogram for two observers,
taking histopathology as gold standard
Confidence of
presence
BIRADS
MG (1)
MG+CEMG(1)
MG(2)
MG+CEMG(2)
Sensitivity
76.5
97
85
97
Specificity
20
40
20
30
PPV
76.5
85
78
83
NPV
20
80
29
75
P value
0.815
0.001
0.687
0.009
Sensitivity
74
82
68
82
Specificity
70
80
80
80
PPV
89
93
92
93
NPV
44
57
42
37
P value
0.012
0.000
0.007
0.000
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: PMC3446357
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
REFERENCES
•
1 Golobocon 2012 released on 12 th dec 2013: http://www.iarc.fr/en/mediacentre/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.
Thank you