Radiological Case: Delineating Extent of Disease Using Contrast-enhanced Digital Mammography

Bhavika K. Patel, MD


Appl Radiol. 2016;45(11):47-49. 

In This Article

Image Findings


The patient received a bilateral 3D mammogram, which demonstrated scattered fibroglandular densities in both breasts. Corresponding to the BB placed over the left upper, central breast area of palpable concern, there is an ill-defined area of architectural distortion in the upper left breast, best seen on tomosynthesis imaging. The left axillary lymph node is enlarged, measuring 2.6 cm (Figure 2). No suspicious microcalcifications are seen. There is no evidence of malignancy in the right breast.

Figure 2.

Mammography demonstrates ill-defined area of architectural distortion in the upper left breast on mammography and an enlarged left axillary lymph node measuring 2.6 cm. Right and left CC (A), right and left MLO (B).

Breast Ultrasound

A targeted left breast ultrasound at 11 o'clock, 5 cm from the nipple, underlying the area of a palpable abnormality, demonstrates an ill-defined hypoechoic mass with posterior acoustic shadowing measuring 1.2 × 1.3 × 0.7 cm (Figure 3). It is difficult to determine if this subtle ultrasound finding corresponds with the tomosynthesis finding of an ill-defined area of architectural distortion in the upper left breast. A subsequent targeted left axillary ultrasound demonstrated a 2.0 × 1.5 × 1.3 cm enlarged lymph node. The greatest cortical thickness measured 7 mm.

Figure 3.

Targeted ultrasound over the left 11:00 5CMFN breast shows an ill-defined hypoechoic mass measuring up to 1.2 cm.

The patient subsequently received a contrast-enhanced digital mammogram (CEDM) because it was unclear if the ultrasound finding corresponded with the initial architectural distortion observed on tomosynthesis. CEDM was also used to better evaluate the extent of abnormal findings.

Contrast-enhanced Digital Mammography

There is minimal symmetric background parenchymal enhancement.

Subtracted Images

In the upper left breast, middle depth, there is a 6.5(AP) × 8.4(ML) ×4.0(CC) cm area of non-mass enhancement, a portion of which corresponds to the area of architectural distortion seen on tomosynthesis. The non-mass enhancement involves both the medial and lateral portions of the upper left breast and is suspicious for multi-centric disease (Figure 4). An enlarged, enhancing left axillary lymph node is discernable. There is no suspicious enhancing mass or non-mass enhancement observed in the right breast.

Figure 4.

CEDM clearly depicts the large area of NME and extent of disease. Note abnormal left axillary adenopathy. Subtracted CEDM right and left CC (A), right and left MLO (B).

The patient received a tomosynthesis-guided biopsy of the architectural distortion in the left breast and ultrasound-guided biopsy of the suspicious left axillary lymph node.