In our current protocol, we initially performed the oblique view, which are the ones that require the greatest collaboration from the patients, thus minimizing the possibility of movement artifacts. We recommend that the study begin with the suspicious breast, with projections interspersed with the asymptomatic breast. In cases where suspicious enhancements are observed, an additional projection of strict profile is performed, which allows obtaining information about late enhancements and also improves anatomical location.
From October 2016 to November 2019 we have performed 1,016 CESM at the Hospital del Mar.
From 2016 to 2018, CESM was carried out using a protocol that was subsequently modified. This change was based on the group's findings and experience as well as an update of the mammograph. In addition, our experience in studying several cases with MRI, taught us that the first protocol did not allow comparing the dynamics of uptake.
Below we present the basic results of both periods:
Previous acquisition protocol
- October 2016 to March 2018
- 342 CESM (with/without biopsy)
- 194 CESM had biopsy
- 0 included in this analysis
Current acquisition protocol
- April 2018 to November 2019
- 651 CESM (with/without biopsy)
- 219 CESM had pathological diagnosis of breast cancer
- 104 included in this analysis
- All had complete information about CESM and pathological diagnosis of breast cancer (invasive: 94, in situ: 10)
- 48 had MRI
We present the descriptive results of 104 cases of CESM with positive biopsy performed with protocol 2 (since 2018).
Breast density
|
|
Frequency
|
%
|
|
|
A
|
5
|
4,8
|
|
B
|
41
|
39,4
|
|
C
|
51
|
49,0
|
|
D
|
7
|
6,7
|
|
Total
|
104
|
100,0
|
|
Background parenchymal enhancement
|
|
Frequency
|
%
|
|
|
Mild
|
42
|
40,4
|
|
Minimal
|
47
|
45,2
|
|
Moderate
|
10
|
9,6
|
|
Marked
|
5
|
4,8
|
|
Total
|
104
|
100,0
|
|
Mammographic findings
|
|
Frequency
|
%
|
|
|
Asymmetry
|
17
|
16,3
|
|
Distortion
|
16
|
15,4
|
|
Microcalcification
|
5
|
4,8
|
|
Mixt
|
4
|
3,8
|
|
Negative finding
|
1
|
1,0
|
|
Nodule
|
61
|
58,7
|
|
Total
|
104
|
100,0
|
|
Number of enhancement focus
|
|
Frequency
|
%
|
|
|
None
|
3
|
2,9
|
|
Bifocal
|
12
|
11,5
|
|
Multifocal
|
16
|
15,4
|
|
Unifocal
|
73
|
70,2
|
|
Total
|
104
|
100,0
|
|
Enhancement pattern CESM (Kinetics)
|
|
Frecuencia
|
Porcentaje
|
|
|
Washout
|
18
|
17,3
|
|
Plateau
|
74
|
71,2
|
|
Progressive
|
12
|
11,5
|
|
Total
|
104
|
100,0
|
|
Subsequently, in this group of 104 CESM with positive biopsy, a second analysis was performed on those patients who also had an MRI. The findings of enhancement kinetics between CESM and RM were compared.
Enhancement pattern
|
|
|
MRI
|
Total
|
Washout
|
Plateau
|
Progressive
|
|
Washout
|
7
|
1
|
1
|
9
|
CESM
|
Plateau
|
11
|
19
|
3
|
33
|
|
Progressive
|
1
|
3
|
2
|
6
|
Total
|
19
|
23
|
6
|
48
|
Concordance rate:
Overall: 58.4%; n= 28/48.
- Washout: 77.7%; n= 7/9
- Plateau: 57.6% n= 19/33
- Progressive: 33.3% n= 2/6
Discordance:
Overall: 41.6%; 20/48.
- Washout: 22.3%; n= 2/9
- Plateau: 42.4% n= 14/33
- Progressive: 66.7% n= 4/6
We must point out that the technique of CESM and MRI are different. On MRI the breast is in decubitus during the entire exploration. At CESM, the patient is standing and the breast is compressed-decompressed and the information from different positions is combined.
These aspects could influence the dynamics of acquisition in the CESM when compared with the gold standard.
Examples of contrast enhancement patterns:
Fig. 2 Background enhancement 4 examples of background collection patterns. These images inform us of the global uptake of glandular tissue.
Fig. 3 Enhancement findings. In this image we see 4 examples of types of lesion uptake.
Fig. 4 Non enhancing findings. In the study of recurrence versus scar, CESM is helpful. If the lesion does not enhance it is more suggestive of corresponding to a scar.
Fig. 5 Mass. In dense breasts, the CESM helps to better define mass lesions.
Fig. 6 Non-mass. The visual analysis of non-mass is more complex when background collection is marked.
Fig. 7 Focus pattern.
Fig. 8 Multifocal pattern.
CESM kinetic enhancement and comparison with MRI:
Fig. 9 Our team has studied the relationship between the type of enhancement of the CESM and the MRI. In this figure you can see two cases of enhancement, type I and II respectively. In the case of type II, it can be seen how the MR plateau pattern coincides with a stability in the uptake in the different views of the CESM.
Fig. 10 Example of washing in CESM. There are two cases. In the second one, it can be seen how contrast washing occurs in late CESM views (ML7 ’).