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

Bhavika K. Patel, MD

Disclosures

Appl Radiol. 2016;45(11):47-49. 

In This Article

Discussion

Contrast-enhanced digital mammography, a commercially available breast imaging modality, is a low-cost imaging tool that provides both a low-energy image comparable to that of digital mammography and a contrast-enhanced reconstructed image similar to that of MRI. Contrast enhancement highlights the neoangiogenesis of breast tumors and is the underlying principle leveraged by both breast MRI and breast CT.[4] Studies have demonstrated that CEDM improves diagnostic accuracy in comparison to both mammography and ultrasound as it further enhances lesion conspicuity.[1]

The lower reported sensitivity of mammography in women with dense breasts is most likely related to a masking effect caused by the large amount of fibroglandular tissue. This particular case, however, demonstrates the ability of CEDM to reveal the extent of disease largely underestimated by both ultrasound and standard mammography despite this patient's non-dense breast tissue.

CEDM was initially recommended to better delineate the abnormality prior to biopsy. Although ultrasound showed a mass of only 1.2 cm, CEDM demonstrated the extent of abnormal enhancement to be greater, measuring 8.5 cm in superior-inferior extent. As a result, the CEDM findings altered clinical management, with the patient receiving neoadjuvant chemotherapy followed by breast conservation therapy. Postsurgical pathology demonstrated residual carcinoma measuring 3.5 cm in a treated tumor bed measuring up to 7 cm (Figure 5).

Figure 5.

Histologic type of invasive carcinoma: Invasive ductal carcinoma. Histologic grade (Nottingham histologic score): 2 of 3 (Tubule formation 3 of 3; nuclear pleomorphism 2 of 3; mitotic rate 1 of 3; combined score 6 of 9)

Studies comparing CEDM to MRI determined that the modalities exhibit similar sensitivity with regard to breast cancer detection[2,3] but higher specificity with CEDM in regard to identifying additional foci in the ipsilateral breast.[3] This case illustrates CEDM's ability to indicate tumor size and extent, which could play a potential role in both pre-surgical and treatment planning.

While MRI is currently the standard of care for contrast-enhanced breast imaging, CEDM may be an alternative with comparable cancer detection sensitivity. This case also demonstrates that CEDM may be considered as an alternative preoperative measurement tool in breast cancer patients and those with limited access to or contraindications to MRI.

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