Digital contrast enhanced mammography (Contrast Enhanced Mammography CEM) is a newer technique that uses iodine contrast to visualize the vasculature of the breast. Pathological vessels formed through the process of neo-angiogenesis in a malignant setting show a different uptake and retention of the contrast agent compared to the normal breast. This contrast corresponds to an iodinated contrast “enhanced” image. This allows the detection of a malignant tumor even in cases with very dense overlying breast tissue.

As it is next, contrast-enhanced mammography (CEM) is basically a combination of digital mammography and iodinated contrast material. In CEM, a dual “phase” mammogram is obtained approximately 2 minutes after the intravenous injection of iodinated contrast. The radiologist has two images per breast and per projection, one as a normal mammogram and one with contrast uptake areas highlighted. The main advantage of the method is precisely this provision of double information regarding both the morphology and the vascularization of the lesion.

The increasing use of CEM in daily clinical practice is reflected in the installation of specialized equipment worldwide, the availability of systems from different vendors, and the number of scientific articles published on the subject. Recent publications report an improvement in sensitivity from 71.5% to 92.7% and specificity from 51.8% to 67.9% compared to digital mammography. Regarding its diagnostic accuracy, previous comparative studies place it at levels almost similar to magnetic mammography and this is expected to be confirmed with the current studies.

It should be emphasized that this examination is not carried out on a case-by-case basis. Digital mammography and digital tomosynthesis are still the standard tests for screening the general population. Contrast-enhanced digital mammography can provide additional information for given and targeted clinical or imaging indications, while at the same time being well tolerated, quick to perform, and more accessible to a greater number of women than magnetic mammography.

Based on the current literature, the indications for implementation of digital mammography with contrast are the following:

1. Resolution of controversial findings detected in conventional breast imaging tests (mammography or tomosynthesis).

2. Management of clinical questions for patients who cannot enter the MRI system. Most often these are patients with pacemakers, allergy to the contrast agent used in Magnetic Mammography, severe claustrophobia or the presence of magnetic field incompatible dilators after mastectomy. The clinical questions that can be answered are the following:

• Preoperative staging of breast cancer to assess the extent of the disease.

• If further suspicious lesions are identified on preoperative staging MRI of patients with known malignancy, CEM may direct preoperative localization or biopsy of the areas in question.

• Screening of the population at increased risk.

• Monitoring response to neoadjuvant therapy in breast cancer patients treated before surgery.

Before performing CEM, it is necessary to check renal function, as in any case of iodinated contrast injection.
As mentioned, the test is very well tolerated, and any allergies related to the contrast injection are mostly mild and self-limiting. Regarding the question of the extra dose of ionizing radiation, it remains within the permissible limits, as determined by the competent European and American committees.

Areas of further CEM research and development include CEM-guided biopsy systems and artificial intelligence applications. Overall, it is expected that this technique will gain an even greater place in the quiver of breast imaging techniques in the coming years.

October is Breast Cancer Awareness Month and a reminder that prevention and early screening save lives. HYGEIA and MITERA, with their new campaign, try to remind every woman how important breast screening is in preventing the disease, asking the simple question:

“Have you been searched?” So let’s make prevention our ally!

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