0:02

Hello and welcome to Noon Conference, hosted by MRI Online

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by creating a free MRI online account.

0:29

Today we're honored to welcome Dr.

0:31

Jordana Phillips for a lecture on

0:33

contrast enhanced mammography, time for implementation.

0:37

Dr. Phillips', chief of Breast Imaging at Boston Medical

0:39

Center and associate professor

0:41

of Radiology at Boston University.

0:44

She's an expert in contrast enhanced mammography performing

0:47

research on the topic, as well

0:48

as lecturing nationally on implementation strategies.

0:52

At the end of the lecture, please join her in a q

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and a session where she will address questions you may

0:56

have on today's topic.

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Please remember to use the q

1:00

and a feature to submit, submit your questions so we can get

1:03

to as many as we can before our time is up.

1:05

With that, we're ready to begin today's lecture.

1:08

Dr. Phillips, please take it from here.

1:11

So, I am so thrilled to be here

1:13

with everybody today talking about

1:15

contrast enhanced mammography.

1:17

It's a topic that I find incredibly exciting for our field,

1:21

and, um, hopefully all of you will too.

1:22

I know there have been a lot of questions about it.

1:24

It's kind of becoming a hot topic.

1:26

People are implementing it, so feel free

1:28

after the lecture is over, if we don't have enough time

1:30

for questions to reach out

1:32

to me, I'm happy to answer anything.

1:33

Um, so let's get started. These are my disclosures.

1:36

Um, so this is what we're gonna be talking about today.

1:39

We'll start with the basics.

1:41

Um, move on to some of the challenges

1:43

of contrasting hand mammography.

1:44

As we know there's always some difficulty when

1:46

you're starting something new.

1:48

Um, we'll talk about how people are using it in clinical

1:51

practice and then we'll move on to, um,

1:53

where it's headed in the future

1:55

and some other kind of key ideas to mention.

1:59

So we're gonna start by talking about the basics.

2:02

The wonderful thing about contrast enhanced mammography,

2:05

and I should start by saying, you'll notice at the top

2:07

of the slide it says CEM contrast enhanced mammography.

2:10

Some people use the word, uh,

2:13

contrast enhanced spectral mammography or CESM

2:16

or contrast Enhanced Digital mammography or CEDM.

2:20

These are all the same thing.

2:21

So, um, I use CEM, so, um,

2:24

you'll see that throughout the talk.

2:26

So the wonderful thing about contrast enhanced mammography

2:29

is that it's just an adaptation of we, what we already know,

2:32

which is conventional 2D mammography,

2:34

which are the standard four views.

2:36

But there are two key differences with a contrast mammogram.

2:40

The first difference is

2:41

that the images are acquired entirely

2:44

after the injection of iodinated contrast.

2:46

So a patient comes into the department,

2:49

they have an IV line placed, which is a difference

2:53

that the patient notes through the IV line.

2:55

They have the I Iodinated contrast administered

2:59

two minutes from the start of the injection.

3:01

They have what they perceive to be their normal mammogram,

3:03

but this is where the second difference comes into play.

3:07

This mammogram is actually performed using a

3:09

dual energy technique.

3:11

And so what does this mean? Well,

3:13

for every imaging position, every time, um,

3:15

the breast is compressed in the CC

3:18

or the MLO view,

3:19

the the unit is actually acquiring two pictures.

3:24

The first picture is a low energy image,

3:26

which looks just like a conventional 2D mammogram.

3:29

You can see it here. Studies have actually shown

3:31

that it's really similar, no different non-inferior

3:34

to conventional 2D mammogram, which is great.

3:38

You'll notice on the low energy image

3:39

that there's already contrast in the breast,

3:42

but you cannot see it on this 2D image on

3:45

the low energy image.

3:47

And that's because this low energy image is performed

3:49

below the cage of iodine.

3:51

So it doesn't capture any of

3:52

that iodine that's in the breast.

3:54

The second image that's acquired is a high energy image.

3:57

You'll notice it's glued out on my screen, and that's

3:59

because it's non interpretable.

4:01

This high energy image is performed

4:03

above the kage of iodine.

4:05

So it captures all of that contrast material that's in,

4:07

in the breast, but we don't, we don't ever see this picture.

4:11

The unit automatically post processes, the low energy

4:15

and the high energy images together

4:17

to create something called a recombined image.

4:19

And this image is similar to a subtraction image on MRI

4:23

where it really just highlights,

4:25

it shows really well those areas of contrast enhancement.

4:29

The low energy image

4:30

and the recombined images are what we see as radiologists.

4:33

Those are the images that get so, get to our workstation,

4:36

um, get sent to our workstation for imaging review.

4:39

So what's excellent about contrast enhanced mammography is

4:43

that we get to combine what we know,

4:44

which is information on morphology and density.

4:47

And we get to combine that with information on enhancement.

4:50

And we don't need an MRI to do it.

4:53

It's all performed at the same time.

4:57

This imaging modality contrast enhanced mammography was

5:00

actually approved over a decade ago at this point.

5:02

Um, it was approved for use in the diagnostic setting in

5:05

2011.

5:06

It's only really increased, um, throughout the country

5:10

in the past few years.

5:13

So let me show you, um, an example of a contrast mammogram.

5:16

This was a 55-year-old woman who had a mass on her screening

5:19

and she was recalled

5:20

and she had a diagnostic contrast enhanced mammo.

5:22

These are her low energy images.

5:24

Again, they look just like a 2D mammogram.

5:27

Remember that, uh,

5:28

the iodinated contrast has already been administered.

5:31

There is already contrast within the breast.

5:33

We just don't see it. So these are the low energy images

5:36

and you can see that there's a mass in the right breast.

5:38

Can't really appreciate its margins that well,

5:41

but then look at the recombined images.

5:43

These are the images that show the enhancement.

5:45

And you can see that there's definitely a mass here.

5:48

You can see the margins of the mass.

5:49

You can see how the mass is taking up that contrast.

5:52

It's heterogeneous necrotic in the center.

5:55

And what you'll also notice is that there's no,

5:57

no enhancement throughout the

5:58

remaining aspect of that breast.

5:59

So not only does it help us better classify

6:03

what we're seeing, better understand it

6:05

or characterize it, I should say.

6:07

It also helps us exclude cancer

6:10

in other portions of the breast.

6:11

This is really great. This was a

6:13

triple negative breast cancer.

6:15

So this is how a contrast mammogram is acquired.

6:18

So again, we start with an injection

6:20

IV line goes in the arm.

6:21

Um, we inject iodinated contrast material at a dose

6:26

of 1.5 ccs per kilogram.

6:28

And at a rate of three Cs per se, three ccs per second

6:31

through a uh, power injector two minutes from the start

6:35

of the injection, we start acquiring the standard

6:37

for images of a mammogram.

6:40

You'll see here each, um, imaging set, so the low energy

6:44

and the high energy image are considered an imaging set.

6:47

Each of these is actually acquired one minute apart such

6:49

that the total exam takes roughly five to six minutes

6:53

if you're gonna perform additional images,

6:56

which sometimes I do, for example,

6:58

I I acquire 90 degree laterals for my diagnostic exams.

7:01

Those happen after the standard four views

7:04

and they have to happen within 10 minutes

7:06

because we wanna make sure

7:07

that whatever contrast is in the breast, we can see it

7:09

and it hasn't washed out.

7:13

What's important to remember

7:14

after the images are acquired, they get sent

7:16

to our workstation, as I mentioned

7:18

before, is that a contrast mammogram includes interpretation

7:22

of both the low energy and the recombined images.

7:25

They are both a part of it.

7:27

So even if you see suspicious abnormality on the low energy

7:32

images right calcifications

7:33

and there's no enhancement,

7:35

that is still considered a positive

7:38

contrast enhanced mammogram.

7:39

And there was actually a meta-analysis that was done

7:42

that looked at data on contrast enhanced mammo,

7:45

and found that when this, when, um, both the low energy

7:47

and the recombined images are included in enhanced in the,

7:50

uh, interpretation, the sensitivity is 95%

7:54

and the specificity is 81%, which is fairly high.

7:57

So it's really important to remember

7:59

that both are included in your interpretation.

8:03

But let's get into a little bit more about the difference

8:06

between contrast enhanced mammography

8:08

versus conventional mammo.

8:09

There are some obvious benefits to start.

8:12

We can see cancers that would

8:13

otherwise be obscured by glandular tissue on a mammogram.

8:16

Let me show you an example or another example of this.

8:19

This was, um, a patient

8:21

who had an asymmetry in the central

8:22

portion of her left breast.

8:23

You can see it's marked here by the circle.

8:25

She came back for a diagnostic contrast mammogram.

8:29

These are the low energy images.

8:31

Again, look just like a 2D

8:33

and you can see the mass there in the

8:34

central aspect of the breast.

8:36

Um, the question is, is it a mass?

8:38

Is it an asymmetry on the low energy images?

8:41

It really looks like a discrete finding.

8:43

When we do the recombined images, we can see

8:45

that there is definitely an abnormality there.

8:47

This is a true finding

8:49

and we can also see that it's limited

8:51

to that portion of the breast.

8:53

And there are no other suspicious area areas

8:56

of enhancement throughout the remaining

8:58

aspect of that breast.

8:59

So again, helps us characterize a lesion

9:02

and also, um, improves our understanding

9:05

of if there are other abnormalities throughout the remaining

9:07

aspect of that breast or the contralateral breast

9:11

studies are consistent.

9:13

I'm not even gonna show you one specific study on this,

9:15

but the studies are consistent in that contrast.

9:19

Enhanced mammography performs better than

9:21

mammo for all performance metrics.

9:22

And this isn't surprising

9:23

'cause it's kind of like pad where it's just, uh,

9:26

taking information that we already have

9:28

and providing more information.

9:30

So we still have our conventional 2D images.

9:32

We're just providing more information, which,

9:34

which is the enhancement to help us, um,

9:37

identify more cancers

9:38

and to help us exclude things

9:40

that are just superimposed breast tissue.

9:43

Another real, um, another nice, uh, characteristic

9:48

of this exam is that it can be performed at the same time

9:50

as the diagnostic appointment.

9:52

So you'll see I already mentioned

9:53

that if I have an abnormality that I identify on screening,

9:56

I can bring the patient back

9:57

and do a diagnostic contrast enhanced mammogram, right then

10:01

I can better evaluate the finding

10:02

and I can actually use it as a staging exam.

10:05

I can see if there's, um, I can see the full extent,

10:07

I can see if there are other areas to worry about.

10:09

And I can do it all at the time

10:11

of the diagnostic appointment.

10:12

I can show the patient the imaging findings.

10:16

It's also when compared to mammography, um,

10:19

it's a timed exam and it's relatively fast.

10:22

So we looked, um, our group looked at

10:24

how long it actually takes to do a contrast mammogram,

10:27

how it com, how it compares to diagnostic mammography.

10:30

You'll see the DMM is for diagnostic mammography.

10:33

So we can figure out how much time we need to schedule

10:37

or allot for this exam.

10:39

So we compared these two, we also compared it to CT and MR,

10:43

but I'm not gonna focus on those.

10:44

And we've looked at different elements of the exam.

10:47

We looked at EST, which is getting the equipment set up,

10:50

PST, which is, uh, getting the patient set up,

10:53

ET is exam time and PT is the post exam time.

10:56

And what you see when you look at all these times taken

10:59

together is that the contrast mammogram was roughly 30

11:01

minutes longer than a diagnostic exam.

11:04

But when we broke that down, we actually found

11:06

that the reason for the increase in length is

11:09

because of that equipment set up time

11:11

and patient set up time.

11:12

And that the actual time for the exam,

11:14

because it's a timed exam,

11:16

was actually exceptionally similar.

11:19

So what that told us is that as you would expect,

11:22

if we use the mammo room to put in the IV line

11:26

and to talk to the patient ahead of time, it's going

11:29

to extend the time of the contrast enhanced mammo exam.

11:32

What's better to do is to actually be able to do all

11:36

of those preparatory steps in another room so

11:40

that you're only using the mammo room for the time

11:42

of the exact, uh, the actual exam, which would be similar

11:45

to a diagnostic exam.

11:48

Another benefit is that, um,

11:50

you don't need a whole new machine or unit.

11:53

It's not like MRI where you have to get the whole,

11:55

your whole, um, the whole room out outfitted

11:59

for this specific modality.

12:00

This is just if you have a mammo unit that's capable

12:04

of being upgraded to allow for dual energy, um, you can,

12:08

you take the machine, um, out of use for about a day or two.

12:13

You have some software firmware upgrade, you have

12:15

to add in a new filter to allow for the high energy images.

12:19

This is a picture of a copper filter also,

12:21

titanium filters can be used,

12:23

but this is really, um, a simple thing to allow you

12:26

to get these, uh, this added information.

12:31

Last thing I'm gonna mention about radiation dose.

12:33

So radiation dose is really a tough topic

12:35

because we all try to compare radiation dose across

12:37

modalities, across vendors and it's very difficult to do

12:40

because all of the vendors

12:43

acquire images in a different way.

12:46

And so it's very hard to compare one to another

12:49

to say there's more or there's less.

12:51

So what we did to get a sense for the actual radiation dose

12:55

of contrast mammo,

12:56

is we took about 40 plus patients in our practice

13:00

who had imaging on all of the different vendors that we had

13:04

and they had all different types of images, 2D 2D plus DBT,

13:08

and we compared the radiation dose.

13:09

We calibrated all of it

13:10

and compared the radiation dose across

13:13

all of these exam types.

13:14

And we stratified our results by breast tissue thickness.

13:17

And what we found is that one of the exams

13:19

that we perform all the time, which was a 2D plus DBT

13:23

for screening, um, we found that

13:25

that was the highest radiation dose across

13:27

breast tissue thicknesses.

13:28

That's that blue arrow still well within the range.

13:31

So I don't wanna suggest that this is a,

13:32

a too high of a dose.

13:34

Um, but just this is what it was.

13:37

A second vendor, which was these were the 2D images only had

13:40

the lowest radiation dose across breast tissue thicknesses.

13:44

And this is where contrast mamm o.

13:45

So contrast mammo was actually, um, the dose of one

13:49

of these exams, which include, uh, low energy

13:52

and recombined, I'm sorry, low energy

13:54

and high energy images was actually similar to,

13:58

was within the range of what we were, uh, providing

14:01

to patients on a daily basis.

14:03

So from my perspective, the take home

14:06

for radi radiation dose, it's not that it's higher

14:08

or lower than a different exam,

14:10

but that it's well within the range of what we're doing

14:12

for women every day.

14:14

But we get this added information on enhancement,

14:17

which we are not getting from our tests

14:19

that only provide morphologic, uh, and density information.

14:23

So let's talk about contrast enhanced mammo compared to MRI.

14:27

Well, there is, the studies have shown a similar accuracy

14:31

of contrast mammo to mr what this means.

14:33

Really it's a measure of how well

14:37

contrast mammo accuracy is a measure of

14:38

how well it finds cancer

14:40

and how well it doesn't find non-cancer.

14:43

So let's look at that. Sensitivity is, um,

14:45

ability to find cancer.

14:47

And these are two meta-analyses, uh, performed in 2020

14:50

and 2022 with a different number of included studies.

14:55

And they found that, um, the first study found

14:58

that the sensitivity for contrast mammo

15:00

and MRI was the same 97%.

15:02

And the second one, more recent one, found

15:04

that there was a difference in sensitivity.

15:06

Contrast hands mammo had a sensitivity of 91%.

15:10

MRI had a sensitivity of 97%, um,

15:13

which was a little bit different

15:15

and actually not unexpected.

15:17

Given that MRI is, um, a cross-sectional imaging exam,

15:21

we're getting much more information than we can on contrast

15:24

enhanced mammo, which is a 2D uh, planar exam.

15:28

But when we look at the specificity, we see

15:31

that the specificity, um, is actually higher

15:34

for contrast enhanced mammo as compared to MRI.

15:37

And this again, really the take home message

15:39

that I would say a majority of us leave when looking at all

15:43

of the individual studies and at these meta-analyses is

15:45

that MRI does do a little bit

15:47

of a better job at finding individual breast cancers

15:49

and by really a few extra, um,

15:53

but it has a much contrast.

15:55

Enhanced mammo has a much better specificity so

15:57

that overall the diagnostic accuracy

15:59

of these two exams is fairly comparable.

16:02

We'll get into, um, the specific clinical,

16:07

uh, how we're using it in clinical practice

16:10

and how the data compares.

16:13

Let's look an example of a contrast enhanced

16:16

mammogram compared to M mri.

16:17

So this is a low energy image from a contrast mammo,

16:19

we see a mass, these are the recombined images

16:22

where we see a mass, but we can also see

16:24

enhancement extending towards the nipple.

16:27

And so let me show you, this is the MRI exam,

16:29

which shows the exact same findings.

16:31

And I would say for people that are new to contrast mammo,

16:34

whenever you look at the recombined images often enough,

16:38

if you were to then perform an MRI, the,

16:40

the images are almost identical.

16:42

Identical as maybe as strong, they're very similar.

16:45

And so how you would describe the imaging finding on the

16:48

recombined images is similar to

16:50

how you would describe it on an MRI.

16:56

Contrast enhanced mammography is also more

16:57

affordable, uh, than MRI.

16:59

We bill it as a diagnostic mammogram plus contrast.

17:02

There's no formal code for it yet.

17:05

It's also more accessible. As I mentioned.

17:07

It's just an add-on to a mammography unit

17:09

that can be upgraded.

17:12

We, it allows for real-time

17:14

interpretation as I also mentioned.

17:16

Um, and so often enough MR MRI is read offline.

17:20

We read them when the patients are not here

17:22

for contrast enhanced mammography,

17:24

we can read them while the patient

17:25

is sitting in our department.

17:26

The number of times that I've done these exams

17:28

and have shown the patients the images

17:30

have shown them when they're totally negative in a patient

17:33

who has dense breast tissue is really comforting

17:35

to these women to know, no, no,

17:37

they can believe these results.

17:39

Or similarly in a patient

17:41

or the contrast mammo is done for staging.

17:43

I can say, no, no, don't worry.

17:44

This, this area is isolated to this one small thing.

17:47

You're good. The rest of your breasts are just fine.

17:50

So, um, this imaging modality allows us to maintain

17:55

that communication with our patients, um,

17:57

especially in this time where I think that

17:59

that communication and connection is important.

18:02

Patients also prefer contrast enhanced mammo.

18:04

This was a study that we recently published.

18:06

These are women who have a history of breast cancer

18:09

and we ask them if both MRI

18:11

and contrast mammo have an equal chance

18:13

of finding your breast cancer, which would you prefer?

18:15

And you can see that far majority,

18:17

73% hopefully like my annotations, um,

18:20

actually would prefer CEM only 10%.

18:23

Um, preferred MRI.

18:26

Another nice thing is

18:27

that we don't have to do an MRI biopsy.

18:30

So for anybody considering CEMI would highly recommend

18:33

that you get CEM biopsy.

18:34

Um, I have not done it myself, but I've seen them

18:37

and they are awesome.

18:39

Um, CM biopsy is just like a stereo biopsy.

18:42

The patient experiences very similar

18:44

and at least what I have perceived is so much better than

18:48

what women are going through for these MRI biopsies.

18:51

So it allows us to divert patients from MRI biopsy

18:55

to CEM biopsy and that's I think, an absolute game changer

18:58

for this imaging modality.

19:01

We're gonna move on to talking about challenges of CEM.

19:04

As I mentioned, you know,

19:05

whenever we, we always have to talk about the challenges,

19:08

there's always something that we need to discuss.

19:10

And the main challenge of contrast enhanced memo really

19:12

relates to contrast administration as you would expect.

19:16

So there's a real risk of contrast related events.

19:19

This includes what we used to call, uh, contrast

19:22

and news nephropathy,

19:23

and now it's called contrast associated

19:26

or contrast induced acute kidney injury.

19:29

Um, and it also includes extravasation

19:31

of the contrast material in the arm

19:33

after it's administered through the IV line.

19:35

Um, contrast associated acute kidney injury

19:38

or contrast induced nephropathy is not really, um,

19:42

it's not really a thing anymore.

19:44

Um, or I should say people are questioning whether it's

19:48

really a thing anymore.

19:49

And so some institutions are actually not even evaluating

19:53

for underlying risk factors for contrast, uh,

19:56

for this contrast complication.

19:58

That being said, the a CR contrast manual still

20:03

still treats it as an entity to be mindful of.

20:06

And so you should talk to your individual institution to see

20:10

how they navigate this.

20:11

Do they test people's renal function before doing, uh,

20:15

before administering contrast?

20:16

Or you can always, um, you can always refer

20:20

to the a CR contrast manual for how to navigate this.

20:23

There's also a challenge

20:25

of contrast administration on workflow.

20:28

Again, we have to place an IV line, we have

20:30

to screen patients to make sure they are not going to,

20:33

they're not at increased risk

20:34

for developing a contrast reaction.

20:36

And so, um, that can impact the

20:39

workflow through the department.

20:42

Another challenge of contrast are, um, false positives.

20:46

So similar to MRI, areas

20:49

that are benign can take up the contrast material.

20:52

That's a challenge. Contrast mammography,

20:55

when we look at it at the moment, it's really just,

20:57

is there contrast or is there no contrast?

20:59

We don't have all of the information that we have with MRI,

21:03

you know, T two signal

21:05

and maybe even diffusion weighted sequences.

21:08

And so there's the real possibility

21:11

to just see abnormal enhancement

21:13

and to say, oh, this is concerning for breast cancer

21:15

and we have to do something about it.

21:17

So there are false positives.

21:18

Let's look at an example of that.

21:20

This was a 56-year-old woman who had a history

21:23

of left breast cancer that was treated

21:24

with wide excision alone

21:26

and she had new right breast calcification.

21:27

So you can see there's the surgical bed

21:29

on the left, I marked it.

21:32

That was where the wide excision was done.

21:34

And these are the new calcifications on the right.

21:36

These are, this is the image showing, you know,

21:38

highly polymorphic, uh,

21:40

linear branching calcifications by RADS five.

21:42

So we are worried about these for sure.

21:45

These are the recombined images that show

21:47

that there's abnormal enhancement associated

21:50

with the new calcifications.

21:51

Not surprising because this, these were

21:53

concerning, they look like cancer.

21:55

But what you'll also notice is that there's um,

21:57

mass enhancement in the surgical bed.

22:00

And we saw this and we thought

22:01

for sure this is gonna be a recurrence.

22:03

This patient didn't have radiation therapy,

22:04

it was only wide excision.

22:06

And so, um, we thought this was gonna be a recurrence.

22:09

We ended up having an MRI

22:10

because this was early on in our implementation.

22:13

We can see the same thing on the

22:14

right with those calcifications.

22:15

We had enhancement and we also saw mass enhancement in

22:18

the surgical bed on the left.

22:20

And it turned out that this was not recurrence

22:23

'cause we did a biopsy and we found that

22:25

that it was just post-treatment change in the

22:27

area of fat necrosis.

22:28

So this is an example of a false positive on contrast,

22:31

mammo and MRI.

22:35

Another challenge of contrast mammo are false negatives.

22:37

Um, false negatives happen

22:41

because you have to remember

22:42

that a contrast mammogram is still just a mammogram, right?

22:46

We're still limited by what you can get on the detector.

22:49

So sometimes you can miss lesions

22:51

that are in the deep chest wall or in the medial breast

22:54

or certainly not imaging the illa,

22:55

but that's not really the goal.

22:58

Another reason for false negative has to do with EPE,

23:02

which is, uh, background parenchymal enhancement.

23:05

So we know from MRI that normal glandular tissue can take up

23:09

contrast to varying degrees.

23:11

Um, same thing happens on a contrast mammogram.

23:14

And you can see the image all the way on the left is minimal

23:17

background pral enhancement where there's almost no uptake

23:21

of the contrast material as compared

23:23

with marked background pral enhancement,

23:26

which is quite a bit of contrast uptake.

23:29

So we have the same four categories on contrast mammo

23:32

as we do with MRI, minimal, mild, moderate and marked.

23:35

And you can imagine that when you have marked a lot

23:38

of background al enhancement, it might be difficult

23:41

to appreciate a solitary area of enhancement.

23:44

And so this can be a reason

23:46

for a false negative on contrast enhanced mammography.

23:50

Another challenge of contrast mammo,

23:52

and this is really an more of an implementation challenge,

23:55

has to do with recombined only findings.

23:57

We know from the literature

23:58

that even if you see an abnormality on recombined imaging

24:01

only, even if it's only one view, you have

24:04

to take these seriously.

24:05

One of the studies that was put out by Kim

24:07

and colleague showed that, um, BCI non mass enhancement

24:11

and mass enhancement had positive predictive values

24:14

of at least 6%, um, all the way up to 40%.

24:18

So you have to address these if you see them.

24:21

And why that's an implementation challenge.

24:23

Is that what happens?

24:25

Um, what do you do in these circumstances?

24:28

The first thing you do is you have to identify,

24:30

see if there's a low energy correlate

24:32

because then maybe you can do a stereo

24:34

or tomosynthesis guided biopsy.

24:36

Well, if you don't have that, you can do, um, an ultrasound

24:39

and see if you have a target

24:41

for ultrasound guided core biopsy.

24:43

But if you don't have that, then what do you do?

24:45

So, um, we used to send these patients

24:47

to MRI to do an MRI biopsy.

24:49

Now with contrast enhanced mammo biopsy, you can do that,

24:52

but you have to know

24:53

how you're gonna navigate these findings.

24:55

Uh, once you implement contrast enhanced mammo

24:58

because it's a real thing, it'll come up

24:59

and you have to address the same.

25:01

At the very least, you would do a follow-up,

25:03

which is not recommended.

25:07

So this is like the whirlwind tour

25:08

of contrast enhanced mammo.

25:10

We're gonna move on to CEM and clinical practice.

25:13

Um, let's start here.

25:15

So, um, there a variety of clinical indications

25:20

for contrast enhanced mammo.

25:22

These are all diagnostic indications as you'll notice

25:24

because I mentioned it's only approved

25:26

in the diagnostic setting.

25:28

And the last one on this list is

25:29

high-risk supplemental screening.

25:31

And that's because, um, there are new recommendations

25:34

that are allowing us to do contrast enhanced mammo in this

25:37

setting, but it is not FDA approved

25:39

or at least allowing us, I should say recommending

25:42

as an alternative to MRI.

25:43

And I'll get into that for this talk.

25:45

We're gonna focus on these first three, um, indications.

25:49

Cancer staging, evaluate neoadjuvant chemotherapy response

25:53

and recall from screening.

25:55

So this is the first case.

25:59

Finally, some pictures.

26:01

This is a 68-year-old woman who is recalled

26:03

for right breast architectural distortion.

26:05

I'm not gonna show you the tomo images.

26:07

You can see the distortion is here

26:08

marked by the yellow arrow.

26:11

When we do the recombined images, you can see

26:13

that there is a discreet mass here.

26:15

And so this, this contrast mammo allowed us

26:19

to both characterize the finding and also delineate extent.

26:23

And that's really one of the, uh,

26:25

beautiful things about this imaging modality.

26:28

It allows us to do both right at the time

26:30

of the diagnostic exam.

26:31

You can also do this after biopsy.

26:34

So this was a grade two, uh,

26:37

hormone receptor positive breast cancer.

26:41

This is another case.

26:42

This is a 68-year-old woman who was recalled again

26:45

for right breast architectural distortion.

26:47

This is the area of distortion.

26:48

It was a very subtle finding,

26:50

not even worth showing you the 2D images.

26:52

Uh, for this particular case.

26:53

These were the recombined images that showed us for sure

26:56

that there's an abnormality in this location.

26:58

But it also showed us that there were other abnormalities

27:00

located in both breasts.

27:02

These were all malignant.

27:03

So this is an example, uh, for sure

27:05

for architectural distortion.

27:07

It helps us say, is this area

27:09

something to worry about or not?

27:12

And is there additional disease

27:14

in other parts of the breast?

27:15

We had an MRI again,

27:17

because this was, um, during the earlier parts

27:20

of our implementation,

27:21

and you can see that these findings showed up on the MRI

27:23

as well and they were all malignant.

27:26

So again, this really just highlights, um,

27:28

how similar the images are

27:30

that we see on those recombined images to our MRI images,

27:33

which is really why the sensitivities

27:35

of the exam is so similar.

27:38

This is another exam,

27:39

but we've talked about distortion so far.

27:41

This is a mass. This is a 75-year-old woman

27:44

who had a history of bilateral breast cancer

27:46

and recalled, uh,

27:47

for diagnostic CMM for this right breast mass.

27:49

Now this what I like about this case.

27:51

We can all see the mass that's marked by the yellow arrow.

27:53

But what I liked about this case and why I'm showing it is

27:56

because we know that once you have cancer treatment,

28:00

it can distort the breast.

28:01

It can be difficult to figure out what is just related

28:04

to the surgery and what is new that we need to worry about

28:08

and remove or treat.

28:10

And so what the recombined images did

28:12

for us is they just showed us where the cancer was

28:16

and all of those other areas of distortion related

28:18

to the post-surgical changes just disappear.

28:21

And this was a grade three, uh,

28:22

hormone receptor PO positive cancer.

28:27

This is another, um, example of contrast mammo.

28:30

This was DCIS. This is for calcifications.

28:32

And calcifications are different than distortion mass.

28:34

And we'll talk about that. This was a patient with DCIS.

28:37

You can see it was already biopsied. That was the clip.

28:39

These are the calcifications.

28:41

Linear branching, very, very suspicious, right?

28:44

Not surprising, this came back as DCIS.

28:47

This person couldn't get an MRI for a disease extent.

28:50

So we did a contrast mammogram

28:52

and what you'll notice is

28:55

that the recombined images shown no enhancement.

28:58

So this is an example

29:00

and the reason why I'm include, I'm including it,

29:03

this is an example still of a positive contrast mammal

29:06

because it's showing those calcifications even though

29:11

it's positive, even though there's no enhancement here.

29:14

And this is one of the challenge of contrast mammo

29:16

for calcifications where some DCIS low grade invasive ductal

29:20

cancers might not show enhancement.

29:22

We have to act on it anyway.

29:24

So when thinking about cancer staging for calcifications,

29:27

we don't actually use the aritha mine images

29:29

to help us determine whether

29:31

to do something about the calcifications.

29:35

It's really to see is there enhancement separate

29:38

or beyond the area of calcifications

29:40

that might impact the overall treatment plan.

29:44

So in summary, here are a few, um, studies

29:46

that I'm just pulling out from the literature.

29:48

Some can now, in 2019, they compared CEM to MRI

29:52

for cancer staging and they found that the sensitivities

29:55

for the primary cancer site are 93% versus 91.

29:58

And if you were to look through the literature,

30:00

you would see this over

30:01

and over again, these sensitivities being

30:02

very similar to each other.

30:05

Um, and they also found that both imaging modality, CEM

30:09

and MRI overestimate the tumor size,

30:12

um, to a similar degree.

30:13

And this overestimation is by a few millimeters.

30:15

We are not talking about centimeters.

30:17

Um, here, lobi etal, uh, more recently

30:21

we're looking at contrast enhanced mammography and MRI, uh,

30:24

and it's value, their evaluation of ILC,

30:26

which is invasive lobular cancer.

30:28

We found that both of them overestimate ILC by

30:31

around two millimeters, very similar.

30:33

And then Lee and colleagues in 2021, look, didn't you know,

30:37

um, um, providing, um, information not on

30:40

how well they found the cancer,

30:43

but on what the positive predictive value, which is really

30:46

how well, when you see something on contrast memoir MRI,

30:50

is it likely to be cancer?

30:51

And you'll see that the positive predictive value is much

30:54

higher for CMM over MRI.

30:56

And this, again, is kind of born out over

30:58

and over again, which is when you see an abnormality on

31:01

contrast nano, it is more likely to be breast cancer

31:04

than when you see an abnormality on MRI.

31:07

And this, um, likely is

31:09

because again, it's A 2D, it's a, it's a planar projection.

31:13

So if it becomes obvious enough for us to see it, um,

31:17

then we should act on it, uh,

31:20

to a greater extent than with MRI.

31:22

And um, yeah, that's the main, that's mainly

31:26

what I have to say about that.

31:28

So in general though, the take home point is

31:30

that contrast enhanced mammography can be used

31:32

as an alternative to MRI.

31:34

So forgetting, you know, the data is there

31:37

and this is what you should remember.

31:41

So now we're gonna look at a different area,

31:43

a different clinical indication, which,

31:44

which is using contrast enhanced mammography to evaluate

31:47

for neoadjuvant chemotherapy.

31:49

So this was a patient who had a grade three, um,

31:52

her two positive breast cancer

31:54

and had a positive lymph node.

31:55

You can see the cancer marked by the thicker arrow

31:58

and the node, uh, marked by the longer thinner arrow.

32:04

And so this is an example where the contrast mammo was used

32:07

to see how the patient responded to treatment.

32:10

So these are the recombined images initially

32:12

before treatment, which show you

32:14

what you would expect the cancer and the node.

32:17

And this is what we see after treatment.

32:20

So, um, the images in yellow are the pre-treatment images

32:23

and the images with the white

32:25

annotations are post-treatment.

32:27

And so on our low energy images we can see

32:30

that it looks like there's improvement,

32:32

but you probably remember from other, uh,

32:36

talks on new adjuvant therapy

32:37

where typically we categorize things as total response,

32:42

no response, and a partial response, which has

32:44

to be at least 30%.

32:46

And so the question is, where does this fall in?

32:47

Is this a partial response? Is this a total response?

32:50

So we get our recombined images,

32:52

which give us a much better sense as to

32:54

how this patient has responded

32:57

to the chemotherapeutic treatment.

33:02

So there was a meta-analysis in 2023 so recent that showed

33:06

that the sensitivity for, um,

33:09

evaluating neoadjuvant chemotherapy treatment response was

33:11

actually better for CEM over MRI.

33:14

And it showed that the specificity was actually a little bit

33:16

worse, 68% to MRI.

33:17

But they're always kind of balancing, you know, these,

33:19

these two imaging exams are always kind of tee teetering.

33:22

Like one is a little bit better, one is a little bit worse.

33:25

Um, Bernardi

33:26

and colleagues in 2022 showed

33:28

that the CEM size measurements correlate highly

33:30

with the size measurements on MRI.

33:32

And studies show variable rates of over

33:34

and underestimates for contrast Malin, MRI,

33:37

but always very similar.

33:38

So it's hard to say, do they

33:39

overestimate it by a few millimeters?

33:41

Do they underestimate it by a few millimeters?

33:43

I don't know what the exact answer for this is

33:46

because the data is kind of like I said, very variable.

33:49

But the take home point is

33:50

that these two imaging exams are very similar

33:53

and that we can use contrast enhance mammography

33:55

as an alternative to MRI for neoadjuvant

33:57

and chemotherapy treatment response especially for sure,

34:00

if you don't have MRI, for sure, for sure.

34:04

So now we're gonna look at recalls, which is, um, an area

34:07

that I really love using it for, especially

34:10

for architectural distortion.

34:11

So this was a really amazing case.

34:14

A colleague of mine, um, recalled this patient

34:17

for exceptionally subtle distortion that was marked here

34:19

by the yellow arrows on tomo.

34:21

Really subtle. We brought her back

34:24

for contrasting enhanced mammo.

34:26

Why do I like it? Well, if it's subtle distortion, right?

34:30

We know that distortion is subjective sometimes, right?

34:32

So somebody can think that there's something there

34:35

and I can look at it and say, I don't see it at all.

34:37

And then there's another group which is

34:39

very obvious distortion.

34:40

We all know that there's something going on.

34:42

So for those subtle distortions, we always have this balance

34:45

of, well, what do we do if our diagnostic imaging is

34:48

negative, then do we still go for a biopsy

34:51

for the initially identified?

34:53

You know, there's, there's so much question about

34:56

what the next step should be.

34:57

So the contrast mammogram helps us decide,

35:00

it gives more information to help triage.

35:02

Is this something to worry about or not?

35:06

And then on the flip side, if it's one

35:07

of those obvious areas of architectural distortion,

35:09

it really helps for staging.

35:10

So this is an example of subtle distortion. Is this real?

35:14

Is it not real? We bring her back and look at that.

35:16

These are the recombined images which show a large area

35:19

of segmental enhancement.

35:21

And this was absolutely real.

35:24

Um, there's no question about it.

35:25

This was an invasive lobular cancer

35:28

and we could tell that there was something to worry about.

35:31

In seconds, minutes, I should say the exam takes minutes.

35:35

So the next example is recall for calcifications.

35:38

And I already mentioned that

35:41

you're gonna act on calcifications that are suspicious

35:44

regardless of whether they're enhance,

35:46

there's enhancement or not.

35:47

So the presence

35:49

or absence of enhancement is only helpful

35:52

if it's larger than the area of calcifications

35:55

and it would impact your management.

35:57

This patient had a very large area

35:59

of calcifications throughout the central

36:01

upper part of her left breast.

36:02

You can see these calcifications here.

36:04

They're pleomorphic, right? These are coming out.

36:07

They were biopsied, they're malignant.

36:09

We do a recombined image.

36:11

We see that there's associated enhancement.

36:13

So like what's the point of this?

36:15

Well, it's helped us know

36:16

that there's no enhancement in the lower part

36:19

of the breast, right?

36:20

We can see that the enhancement

36:22

and at least the disease is isolated

36:24

to this area of calcifications.

36:26

And it's also given us information about the right breast.

36:29

So when you consider evaluating con

36:32

or using contrast memo for calcifications, it's really

36:35

to say, what, how is this going to help me?

36:37

I'm already worried about the calcifications.

36:39

I'm, look, I have to look for something more.

36:41

And if tho that additional information will

36:43

help me, then it's worth doing.

36:45

This is DCIS.

36:48

This was a recall for a possible mass.

36:51

So there was the possible mass, you can see it better, um,

36:53

in the upper outer left breast.

36:54

You can see it better on the MLO view.

36:57

When you do the recombined images, you can see

36:59

that there's this very discreet mass.

37:01

I mean, look at that. This is a woman

37:02

who has dense breast tissue, hard

37:04

to differentiate anything, right?

37:07

If there's a subtle mass located within the dense breast

37:10

tissue and then we do the recombined images

37:12

and all of the normal breast tissue goes away

37:14

and we see the mass, we see the size of it,

37:17

we see the extent of it,

37:18

and we can look at the contralateral breast

37:19

and say, okay, this is really what we're talking about,

37:22

this one small area.

37:25

So now let's look at the data.

37:27

Um, for architectural distortion.

37:28

Again, this is an area that I really love.

37:30

The telling colleagues published the first study on this in

37:33

2017, and they said that, um,

37:37

enhancement was associated with 30, I'm sorry, with 29

37:42

of the 30 cancers.

37:44

So there was one cancer in their study

37:47

that was not clearly associated with enhancement,

37:50

but that person had marked background

37:52

prank, more enhancement.

37:53

So it's difficult to know if it really wasn't associated

37:56

with enhancement or it just wasn't perceived

37:58

to be associated with enhancement.

38:00

In 2021,

38:01

there was another study done on architectural distortion

38:04

and said that if there was no enhancement, you do not have

38:07

to worry about this thing.

38:08

So between these two,

38:11

the real take home is if there is no enhancement

38:15

in a patient who has no background premal enhancement

38:18

or very little background premal enhancement, the likelihood

38:21

that that is cancer is very, very low.

38:23

Once somebody has a lot of background premal enhancement

38:26

where it can impact your perception, your identification

38:29

of abnormal enhancement, you wanna be a little bit, uh,

38:32

more cautious calcifications,

38:35

most invasive breast cancers enhance,

38:38

but there are some invasive or DCIS, uh, invasive cancers

38:42

or DCS that may not enhance.

38:43

This is similar to MRI.

38:45

And so we want to evaluate calcifications with suspicious,

38:48

suspicious morphology regardless of enhancement.

38:52

And I talked already a little bit about, uh, when

38:55

to use contrast enhanced mammo for these cases.

38:59

Next we'll talk about masses.

39:01

Um, masses that are associated

39:04

with enhancement are more likely

39:05

to be malignant if a mass has no,

39:08

if you have a mass on a low energy exam

39:11

and there's no associated enhancement,

39:12

the negative predictive value is very high.

39:15

And that's no different than if you see a mass on a 2D

39:17

mammogram and you do an MRI and you see no enhancement.

39:21

That's the likelihood that

39:22

that is a cancer is essentially zero.

39:24

I mean, there is no, it's,

39:25

it's the negative predictive value of an absence

39:28

of enhancement for a mass is very, very, very high.

39:33

So we talked about, uh, some of the clinical indications,

39:36

how people are using it, some of the data.

39:38

Now we're gonna talk about

39:40

where things are headed in the future.

39:42

Um, there are three main areas that we're talking about,

39:44

which is breast cancer screening using contrast mammo, um,

39:49

in the diagnostic setting just

39:50

to formalize those indications a little bit.

39:53

And then radio mix, which is AI and machine learning

39:55

and really, really neat stuff is happening.

39:58

So we'll talk about breast cancer screening.

40:00

This is, um, this is a topic that I think most of us

40:04

who use contrast mammo, most of us, most people who who

40:08

see tox on contrast mammo, this is the area

40:10

that we're most excited about, especially for women

40:13

who have dense breast tissue who are at high risk.

40:15

Maybe they don't qualify for an MRI

40:19

can we do a better job at finding breast cancers

40:22

for these women above what we're already able to do

40:25

for tomosynthesis with tomosynthesis and ultrasound.

40:28

So this is a patient, um, who has,

40:32

is high risk for breast cancer.

40:33

She had a contrast mammo. This was a screening exam.

40:35

You'll see the, um, low energy images were negative

40:39

and then we do the combined images

40:41

and we can see, um,

40:42

a hormone receptor positive cancer in the right breast.

40:45

And so this is kind of what we're talking about.

40:48

We're talking about identifying cancers that we would

40:51

otherwise miss on our conventional imaging.

40:53

I mean, this is, this is why we're excited about MRI.

40:56

So, um, the problem is that the data is, uh, is not

41:00

yet there where we can do contrast mammo for screening.

41:03

Certainly it has not been FDA approved for this indication.

41:08

So let's talk about the data.

41:10

Um, we have retrospective studies, reader studies,

41:14

and then there's Seima Seima, which is really,

41:16

really excellent that have already been, um,

41:20

seima is is happening now, but there are some retrospective

41:22

and reader studies that are out.

41:24

So soaring colleagues in 2018

41:28

compared contrast enhanced mammography, the full exam,

41:31

low energy and combined images to, um, the low energy alone,

41:34

which is kind of a surrogate for mammography.

41:36

And they found an additional 13

41:39

breast cancers per thousand women screened.

41:42

2019. The MSK group looked at their data for contrast mammo

41:47

and they found a cancer detection rate

41:48

of 15 per thousand women's screened,

41:50

which is much higher than the standard, uh,

41:53

cancer detection rate rates.

41:55

We typically talk about with mammo

41:56

or with tomosynthesis, which is about, you know, three

42:00

to five, three to six breast cancers per thousand.

42:02

There are also retrospective studies on, uh, women

42:06

who have had a history of breast cancer, those

42:08

that are above average risk.

42:09

Women who have dense breast history of lobular neoplasia,

42:12

and they all say the same thing, which is

42:14

that contrast mammo does a better job than conventional.

42:16

Mammo emis though is really gonna be, um, the test,

42:22

the trial that helps differentiate Should we be doing this?

42:26

It's a prospective trial, it's a multi-center trial.

42:29

What SIMAS is doing, it's recruiting about 2000 women.

42:33

These women are getting both tomosynthesis

42:35

and contrast mammo.

42:37

And it's gonna be able to see

42:39

what the difference is in cancer detection

42:41

and also what the difference is in false positives

42:43

because that impacts, um, our view

42:46

of whether this is a good screening test.

42:48

And they'll track, um, you know, contrast reactions

42:51

and what, so that we can really get an overall look at

42:54

how this modality plays for women

42:56

who have dense breast tissue, the good and the bad,

42:58

and compare it and see if this is something we wanna do.

43:01

The results of that should be out in a few years.

43:02

It's very exciting. Uh, stay tuned.

43:08

My group published, um, a trial more recently

43:11

that compared contrast enhanced mammo to MRI

43:14

for breast cancer screening.

43:15

We had 132 CEM

43:18

and MRI exams in an asymptomatic, uh, population

43:21

of women 132.

43:22

That's a huge number. And we had 12 people,

43:25

12 radiologists look at all of these exams

43:28

and we compare the performance metrics.

43:30

And what we found as expected is

43:32

that CEM performed a little bit worse than

43:34

the full MRI protocol.

43:35

You can see CM sensitivity was 89%,

43:38

whereas the full MRI was at 94%.

43:40

But look at the sensitivity of 2D mammography, which was 70,

43:43

75%, much lower.

43:47

Um, we found that the specificity

43:49

of contrast mammo was higher than the full MRI protocol,

43:52

which again, is what we'd expect.

43:54

Fewer false positives.

43:55

When we see something on a, on an MRI on a contrast mammo,

43:58

it's more likely to be breast cancer.

44:01

And when we look at that metric of accuracy, which is a UC

44:05

to see how, what the balance is between cancer detection

44:09

and, um, not finding benign things, we see

44:14

that actually the the accuracy is very similar

44:17

between both of these exams.

44:19

And we confirmed that

44:21

contrast enhanced mammography is non-inferior to breast MRI.

44:25

And this was great. I mean, we looked at a lot of cases

44:27

and we had a lot of people look at it.

44:29

And so this helps perpetuate the idea, move forward.

44:32

The idea that these two exams are very,

44:34

very similar overall, unfortunately, again, as I mentioned

44:39

before, we don't have enough data yet to, um,

44:43

to really embrace this fully for breast cancer screening.

44:45

Certainly the organizations that guide us have not done so.

44:50

And so really, um, where we're at

44:52

for screening is the a CR has acknowledged that

44:56

CMM has value, but that there's limited data.

44:58

And so it's really only recommending it when MRI

45:01

cannot be performed.

45:02

I imagine this will change over time,

45:04

but this is where we stand today.

45:06

The NCCN,

45:07

which is the National Comprehensive Cancer Network,

45:09

has a similar approach.

45:10

Really use contrast mammo

45:12

for breast cancer screening when you can't perform an MRI.

45:16

Same thing with U obi,

45:17

which is the European Society of Breast Imaging.

45:19

So that's kind of where we're at.

45:21

I imagine that will, um,

45:22

things will change over time, as I mentioned.

45:25

Another area to, um, for the future is there's a,

45:30

we're gonna look at how contrast mammo specifically applies

45:34

to palpable lumps, pathologic nipple discharge,

45:37

high risk screening, evaluation,

45:38

and screening recalls, more studies to see, to see

45:42

how it compares to our standard of care.

45:45

There's a great trial called, um,

45:48

it's called the Racer Trial, rapid access

45:50

to contrast enhanced spectral mammography in women recalled

45:52

from breast cancer screening.

45:54

This trial, um, is doing is randomizing patients to

45:59

standard of care, which is mammography ultrasound

46:02

versus CEM.

46:04

And they're gonna look at what the different performance is

46:06

in terms of cancer detection, follow ups,

46:09

biopsies, et cetera.

46:11

Uh, missed cancers.

46:12

So that is gonna be really one of, uh, this is gonna,

46:15

the results of this trial are gonna be really great

46:17

to help us figure out is contrast mammo better?

46:19

Maybe it has a slightly better

46:21

or better cancer detection rate,

46:23

but maybe, um, there are other challenges

46:25

that we need to be mindful of.

46:28

Lastly, for future directions,

46:29

we're gonna talk about radios.

46:32

Uh, radios are really looking at differentiating cancer

46:36

subtypes, trying to figure out can we use

46:40

contrast mammo in the contrast that we see on these images

46:42

to differentiate benign from malignant disease.

46:45

And lastly, to evaluate x lary metastases

46:50

overall, the wonderful thing is

46:52

that c guided core biopsy is now available.

46:56

You can get it, it's amazing.

46:58

Um, I'll show you an example of how that's used.

47:00

I know we're running out of time.

47:02

So this was a patient who had a recombined only finding, um,

47:07

let me show you this.

47:09

So this was a patient who had architectural distortion in

47:11

the left breast marked by that yellow arrow.

47:14

And we did a biopsy, a tomosynthesis guided biopsy.

47:17

And you'll see that our clip is actually not

47:19

where the tomosynthesis,

47:21

where the architectural distortion was.

47:23

So we weren't sure what to do about this.

47:25

Did we sample appropriately, the distortion

47:28

and the clip moved or were we just off?

47:30

And this can happen with tomosynthesis guided biopsy.

47:32

I imagine everybody on the call,

47:35

or at least many people on the call have had this issue.

47:38

So we did a contrast mammo to get more information

47:41

and we found that there was no enhancement in the error

47:44

of distortion, which is great,

47:47

but there was enhancement in the right breast.

47:49

The enhancement here marked

47:50

by the pink color was adenoma, known adenoma.

47:53

But you'll see that there was actually an incidental

47:55

enhancement in the, um, outer central right breast.

47:59

And this was, this was a malignancy.

48:01

So, but what we're,

48:02

you know, what are we gonna do with this thing?

48:03

We sent her to ultrasound, we couldn't find it.

48:05

There was no associate correlate on the low energy exam,

48:08

so we had to send this patient to MRI.

48:11

Um, but now with contrast enhanced mammo biopsy,

48:13

we'll be able to do that.

48:16

Another notable change is that there's now a lexicon for how

48:20

to interpret the imaging findings,

48:21

which obviously I've not gone into any information about how

48:24

to interpret the images that we see.

48:26

Mostly the lexicon is based on, is built

48:29

around the low energy images being similar to mammography

48:32

and the recombined images being similar to MRI.

48:36

So the lexicon is really geared towards mammography

48:38

and MRI uh, characteristics.

48:40

The main changes are that there's not no focus, there's no

48:44

the, the term focus is not included in the CMM lexicon.

48:48

We don't have the characteristics of, um,

48:50

dark internal citations clustered ring.

48:52

And we've added a term called enhancing asymmetry,

48:56

which is a finding that you see an area of enhancement

48:59

that you see only on one view.

49:02

And so at that, this is the summary of the talk.

49:05

I'm actually not gonna stay on this slide too long

49:06

because I know we're running out of time

49:08

and I wanna give people a chance to ask some questions

49:13

so you can always learn more.

49:14

These are some, there are some books available, websites,

49:17

journal articles, and feel free to reach out

49:19

with questions anytime.

49:22

Thanks so much for your lecture, Dr. Phillips.

49:24

At this time we will open the floor for some questions.

49:27

You can submit those through the q and A feature

49:30

and we will try to get through as many as we can.

49:33

We have a few coming in

49:35

and I will go ahead and open this up.

49:38

How much iodinated contrast do we administer for CEM?

49:43

Um, so the dose of contrast is largely,

49:48

um, so it's weight based.

49:50

And so, um, the actual dose is built

49:54

around the patient who walks in the door.

49:55

So we weigh the patients

49:57

and the imaging units, you plug in the weight

50:01

and it tells you what the dose should be.

50:03

Often enough institutions have a maximum

50:06

dose that they administer.

50:07

So our maximum dose is 150 ccs

50:12

ml I should say.

50:17

If you, the weight based, go ahead. I'm sorry.

50:19

The weight-based, um, calculation is 1.5 ccs per kilogram.

50:25

Thank you. If you work up in an asymmetry with CEM

50:29

and see no enhancement, how confident can you be

50:33

that the asymmetry is benign?

50:34

Does it become birads three or birads two?

50:38

So, um, that, this is a really great, great question

50:41

and it's one of the challenges of contrast mammos.

50:43

What do you do with these?

50:45

Enhance what we call now enhancing asymmetries,

50:48

which are areas of enhancement on one view only.

50:51

And the answer is, is really you

50:53

need to be concerned about it.

50:54

I would not blow these off.

50:56

Um, so typically

50:58

what we do now is you look at your low energy images

51:01

and you see if there's a mammo correlate

51:05

to help you figure out is this enhancement,

51:07

perhaps it's associated with an area on the 2D mammogram

51:11

that's been there for 10 years, in which case, yes,

51:13

it's enhancing, but you're using the other features

51:15

to tell you no, no, it's enhancing

51:17

associated with a benign finding.

51:19

But if you are not able to get, um, a low energy correlate,

51:23

then you would do a targeted ultrasound.

51:25

But I would say you do not necessarily call it a

51:27

BIRADS three or birads two.

51:29

You would, you would wanna work it up

51:30

and then if you absolutely have no correlate on your mammo

51:34

or ultrasound, then um, what we had been doing

51:37

before CM biopsy was actually sending the patient to MR

51:40

to further evaluate it.

51:42

And now that CMM biopsy is around, you can do a CMM biopsy.

51:47

Very rarely do I follow it.

51:50

Thank you. Does CEM have the same sensitivity

51:54

for non-MS enhancement?

51:56

Comparable to MRI? This is in regard to high grade DCIS.

52:00

I don't have the answer for that question,

52:02

specifically tommas enhancement.

52:06

Okay. Um, can you clarify, does CEM only use 2D

52:10

and not tomo images?

52:13

Yeah, that's a, that's a great question.

52:14

So CEM is a planar exam, it's just 2D.

52:18

So, um, when the exam is acquired,

52:20

think about your 2D mammos

52:22

and um, that's exactly how it's done.

52:26

There's no tomo sweep.

52:28

There are people that are talking about contrast enhanced,

52:32

uh, tomosynthesis where

52:34

during the tomo sweep you're performing

52:36

your dual energy images.

52:37

There are people that have studied that,

52:39

but that's not available now.

52:43

Got it. We've got two questions in the insurance

52:46

reimbursement billing area, can you speak

52:49

to your experience on, on this?

52:51

Do you have to get pre-authorization prior to performing?

52:54

No. And how do you bill? Okay.

52:55

No, it's billed as a diagnostic mammogram plus the

52:58

administration of contrast.

53:00

So it's just a diagram and then the contrast often enough,

53:03

depending on where you work, hospital,

53:05

or non-hospital related, you may

53:06

or may not get reimbursed for the contrast.

53:08

The contrast is roughly like $12.

53:10

So at the moment that is, um, how it's billed

53:14

and there's not typically an insurance coverage issue.

53:18

I hope that I've answered, you know, the people

53:20

that have questions about reimbursement,

53:22

I hope, hope I've answered them.

53:26

We all would like to get reimbursed more

53:28

and have a dedicated CPT code for it,

53:30

but that's not, that's not

53:31

happening, that's not a thing yet.

53:35

Alright. Um, does the compression affect the enhancement?

53:43

I think whoever asked that question, I'm interested

53:45

to know, I to know what you're specifically asking about.

53:50

So, um, the de so the degree of compression, I can't answer,

53:55

I can only say that a contrast mammogram is, is done

54:00

where you administer the contrast of the patient sitting

54:03

and then you do the mammogram.

54:05

So the patient gets put in compression

54:06

after the contrast, it is administered.

54:10

That is how these exams are done.

54:12

And so at the moment, it does not seem

54:14

to impact our ability, our, our, um, capability

54:18

of seeing the enhancement.

54:21

Now I cannot answer the question about like the degree

54:23

of compression and how it impacts

54:30

In your experience with any surgeons,

54:32

have they liked CEM versus pre-op MRI?

54:35

Oh my God, our surgeons love it.

54:37

Every surgeon that I've spoken to has loved it,

54:40

and I think that the challenge, um, the,

54:42

the reason why the surgeons love it is

54:44

because one of the challenges of MRIs, yes, MRI is,

54:46

is an amazing tool and I really don't wanna diminish it

54:49

because it's been, you know, an amazing boon for our,

54:52

um, for our field.

54:54

It finds many cancers,

54:56

but it also finds a lot, a lot of non-cancerous.

54:59

And these women are going for more biopsies, more stress,

55:03

they, which is associated with more stress.

55:05

And so our surgeons are really liking it

55:08

because if we see an abnormality,

55:10

we can do something about it.

55:11

There are fewer false positives, fewer extra visits,

55:15

and so they appreciate the ability to identify just

55:18

what we need to know and not anything more surgeons love it

55:22

and it doesn't delay care.

55:24

You know, you can do it right in the mammo suite.

55:29

Awesome. Got it.

55:30

They're talking about it at their conferences too.

55:34

Uh, contrast Nemo.

55:37

Awesome. Can we do dynamic

55:40

contrast enhanced study Enhancement Curve with CEM?

55:45

So, um, that is not a part

55:49

of the exam currently.

55:52

We do not do that currently.

55:53

There are a number of studies that have looked at looking at

55:59

how the breast takes up contrast

56:02

or how a lesion takes up contrast over time

56:05

to help us differentiate cancer from not cancer.

56:08

That has not been, um,

56:11

included in our current interpretation of the exam.

56:15

It's not as consistent as it is with MRI,

56:18

where you're looking at the breast, you know,

56:20

you're looking at every portion

56:21

of the breast at at the same time, you know,

56:23

at the same time over multiple time periods.

56:30

What do you do with multiple small foci

56:33

of less than five millimeters of enhancement

56:38

On MRI or on contrast? Mammo,

56:40

I think it's about contrast mammo.

56:42

Um, I you, so, so this is also an interesting question

56:47

because with MRI, when MRI was started,

56:51

there were a lot more follow-ups.

56:54

And the reason why there were more follow-ups

56:55

for this specific indication is

56:57

because we didn't have the data to say, oh,

56:58

this is just BPE versus not.

57:01

And I would say at the moment, the, the standard practice

57:04

for this is variable among practices

57:06

and how comfortable you are.

57:08

Um, if you were to see multiple scattered enhancing foci,

57:12

none of which stood out as being

57:14

definitively different than everything else,

57:17

I would just call it a birads two in background.

57:19

Um, if there was one

57:21

that really looked a little bit different

57:23

or if I couldn't tell is there something here

57:25

that I'm missing and I'm questioning certain areas,

57:28

then I would do a follow-up.

57:29

I'm comfortable doing a follow-up

57:31

because I don't have the same amount of data long-term data

57:34

to say, oh, this is really just all background, being able

57:38

to differentiate background from it from

57:39

an abnormal enhancement.

57:41

So I would say the short answer is

57:43

I am comfortable if I see multiple scattered, um, areas

57:46

of enhancement, which we call foci less than five

57:50

millimeters all throughout the breast, calling it mark BPE

57:52

and not doing more for it.

57:53

If there's one specific area I'm questioning something,

57:55

I would also feel comfortable doing a follow up.

57:59

Thank you. All right.

58:00

I'll ask two more questions and we'll let you go.

58:02

You've got tons of questions here.

58:05

Um, do you always repeat CEM

58:07

after biopsy to confirm clipp placement?

58:12

Is that after a CEM biopsy? I, I, oh,

58:16

Great question. If

58:17

After CM biopsy, I'm not able to answer that question.

58:19

We don't routinely, in general, I do not perform CEM

58:23

after biopsy to confirm click placement.

58:26

Um, and for CEM biopsy,

58:28

I can't answer that because I don't do those.

58:30

So I cannot tell you what I would normally do.

58:33

Is there a recommended timeframe

58:35

for image acquisition in CEM after contrast administration?

58:40

So the standard thought is that two minutes from the start

58:43

of the injection is when you start acquiring the pictures

58:47

and you wanna image within 10 minutes to make sure

58:50

that the contrast material that's in the breast is still

58:52

there, hasn't washed out yet.

58:56

Okay. One more question.

58:58

In young patients with breast cancer,

58:59

do you prefer MR over CEM?

59:02

So

59:04

For newly diagnosed breast cancer, I would say that

59:09

currently my answer largely has to do with logistics

59:16

and it has to do with when the patient's gonna be able

59:19

to come in for the mr when the patient's gonna be able

59:21

to come in for contrast.

59:22

Often enough, if I see a young woman who's coming in, um,

59:26

we will do the contrast mammal right at the time

59:28

of the diagnostic exam.

59:29

And so I don't actually have to bring the patient back

59:32

for a contrast mammo or an MRI.

59:34

If I've already done a workup

59:36

and then I've diagnosed the cancer

59:40

and I'm now doing a contrast study for extended disease,

59:44

it really would be a logistical choice

59:47

and the location of the, uh, cancer.

59:49

So if the cancer is located deep within the breast

59:52

or medial, then um, then I would choose MRI

59:58

Thank you Dr. Phillips for answering all those questions

60:00

and thank you for your lecture today.

60:02

That was wonderful. Appreciate you being here.

60:06

Absolutely. I'm happy to, if anybody has any

60:08

other questions, I don't know.

60:10

I really have not been following to see

60:12

what other questions there are,

60:13

but anybody should feel free to reach out.

60:16

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60:18

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