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Let's get into a little bit more about

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the difference between contrast-enhanced

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mammography versus conventional mammo.

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There are some obvious benefits. To start,

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we can see cancers that would otherwise

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be obscured by glandular tissue on a mammogram.

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

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This was, um, a patient who had an asymmetry

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in the central portion of her left breast.

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

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She came back for a diagnostic contrast mammogram.

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These are the low-energy images.

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Again, look just like a 2D, and you can see the

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mass there in the central aspect of the breast.

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Um, the question is, is it a mass?

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Is it an asymmetry?

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On the low-energy images, it really

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looks like a discrete finding.

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When we do the recombined images, we can see

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that there is definitely an abnormality there.

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This is a true finding, and we can also see

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that it's limited to that portion of the breast.

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And there are no other suspicious areas of enhancement

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throughout the remaining aspect of that breast.

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So again, helps us characterize a lesion,

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and also, um, improves our understanding of if there

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are other abnormalities throughout the remaining

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aspect of that breast or the contralateral breast.

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Studies are consistent.

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I'm not even gonna show you one specific

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study on this, but the studies are consistent.

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In that contrast-enhanced mammography performs

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better than mammo for all performance metrics.

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And this isn't surprising, 'cause it's kind of like

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CAD, where it's just, uh, taking information that

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we already have and providing more information.

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So we still have our conventional 2D images.

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We're just providing more information, which,

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which is the enhancement to help us, um,

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identify more cancers and to help us exclude

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things that are just superimposed breast tissue.

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Another real, um, another nice—

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uh, characteristic of this exam is that it can be

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performed at the same time as the diagnostic appointment.

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So you'll see I already mentioned that if

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I have an abnormality that I identify on

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screening, I can bring the patient back and do

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a diagnostic contrast-enhanced mammogram, right

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then. I can better evaluate the finding,

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and I can actually use it as a staging exam.

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

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I can see if there are other areas to worry about, and I

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could do it all at the time of the diagnostic appointment.

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I can show the patient the imaging findings.

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It's also, when compared to mammography, um,

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

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So we looked, um, our group looked at how long it

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actually takes to do a contrast mammogram, how it

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com—how it compares to diagnostic mammography.

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You'll see the DM is for diagnostic mammography,

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so we can figure out how much time we

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need to schedule or allot for this exam.

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So we compared these two.

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We also compared it to CT and MR,

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but I'm not gonna focus on those.

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

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We looked at EST, which is getting the

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equipment set up; PST, which is, uh, getting

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the patient set up; ET is exam time,

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and PT is the post-exam time.

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And what you see when you look at all these times

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taken together is that the contrast mammogram was

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roughly 30 minutes longer than a diagnostic exam.

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But when we broke that down, we actually found

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that the reason for the increase in length—

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is because of that equipment set-up time and patient set-

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up time—and that the actual time for the exam, because

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it's a timed exam, was actually exceptionally similar.

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

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

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

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extend the time of the contrast-enhanced mammo exam.

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What's better to do is to actually be

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able to do all of those preparatory steps

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in another room so that you're only using the mammo

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room for the time of the exact—uh, the actual—

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exam, which would be similar to a diagnostic exam.

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Another benefit is that, um, you don't

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need a whole new machine or unit.

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It's not like an MRI where you have to get

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the whole—your whole, um—the whole room

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outfitted for this specific modality.

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

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capable of being upgraded to allow for dual energy,

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um, you can—you take the machine,

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um, out of use for about a day or two.

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You have some software/firmware upgrade.

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You have to add in a new filter to

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allow for the high-energy images.

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This is a picture of a copper filter.

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Also, titanium filters can be used, but this

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is really, um, a simple thing to allow you

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to get these, uh, this added information.

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Last thing I'm gonna mention about radiation dose.

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So radiation dose is really a tough topic because we

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all try to compare radiation dose across modalities,

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

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all of the vendors acquire images in a different way.

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

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

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So what we did to get a sense for the actual

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radiation dose of contrast mammo, is we

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took about 40 plus patients in our practice

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who had imaging on all of the different vendors that

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we have, and they had all different types of images,

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2D, 2D plus DBT, and we compared the radiation dose.

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We calibrated all of it and compared the

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radiation dose across all of these exam types.

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And we stratified our results by breast tissue thickness.

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And what we found is that one of the exams that we perform

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all the time, which was a 2D plus DBT for screening—

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we found that that was the highest radiation

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dose across breast tissue thicknesses.

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That's that blue arrow—still well within the right, so I

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don't wanna suggest that this is a, a too high of a dose.

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Um, but just—this is what it was.

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A second vendor, which was—these were the

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2D images only—had the lowest radiation

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dose across breast tissue thicknesses.

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And this is where contrast mammo fell.

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So contrast mammo was actually, um, the

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dose of one of these exams, which include—

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low energy and recombined—I'm sorry, low energy

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and high energy images—was actually similar to—

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within the range of what we were, uh,

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providing to patients on a daily basis.

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So from my perspective, the take-home for radiation

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dose is not that it's higher or lower than a

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different exam, but that it's well within the

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range of what we're doing for women every day.

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But we get this added information on enhancement,

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which we are not getting from our tests that only

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provide morphologic, uh, and density information.