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So, I am so thrilled to be here with everybody

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today, talking about contrast-enhanced mammography.

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It's a topic that I find incredibly exciting for

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our field, and, um, hopefully all of you will too.

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

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It's kind of becoming a hot topic.

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People are implementing it, so feel free after the lecture

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is over, if we don't have enough time for questions,

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to reach out to me. I'm happy to answer anything.

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Um, so let's get started.

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These are my disclosures.

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

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We'll start with the basics.

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Um, move on to some of the challenges

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of contrast-enhanced mammography,

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as we know there's always some difficulty

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when you're starting something new.

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

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practice and then we'll move on to, um, where it's headed

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in the future and some other kind of key ideas to mention.

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

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The wonderful thing about contrast-enhanced mammography,

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

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of the slide it says CEM, Contrast-Enhanced Mammography.

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Some people use the word, uh, contrast

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Enhanced Spectral Mammography or CESM, or

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Contrast-Enhanced Digital Mammography, or CEDM.

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These are all the same thing.

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So, um, I use CEM.

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So, um, you'll see that throughout the talk.

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So the wonderful thing about contrast-enhanced

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mammography is that it's just an adaptation of

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what we already know, which is conventional

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2D mammography, which are the standard four views.

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But there are two key differences

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with a contrast mammogram.

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The first difference is that the images are acquired

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entirely after the injection of iodinated contrast.

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So a patient comes into the department, they have an IV

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line placed, which is a difference that the patient notes.

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Through the IV line, they have the iodinated contrast

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administered. Two minutes from the start of the injection,

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they have what they perceive to be their normal mammogram,

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but this is where the second difference comes into play.

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This mammogram is actually performed

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using a dual-energy technique.

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And so what does this mean?

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Well, for every imaging position, every time, um,

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the breast is compressed in the CC or the MLO view,

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the unit is actually acquiring two pictures.

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The first picture is a low-energy image, which

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looks just like a conventional 2D mammogram.

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You can see it here.

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Studies have actually shown that it's really

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similar, no different, non-inferior to a

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conventional 2D mammogram, which is great.

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You'll notice on the low-energy image that there's already

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contrast in the breast, but you cannot see it on this 2D

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image, on the low-energy image, and that's because this low

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energy image is performed below the K-edge of iodine, so it

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doesn't capture any of that iodine that's in the breast.

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

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You'll notice it's blued out on my screen,

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and that's because it's non-interpretable.

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This high-energy image is performed above the

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K-edge of iodine, so it captures all of that

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contrast material that's in the breast,

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but we don't, we don't ever see this picture.

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The unit automatically post-processes the

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low-energy and the high-energy images together

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to create something called a recombined image.

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And this image is similar to a subtraction image on

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MRI, where it really just highlights, it showed

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really well those areas of contrast enhancement.

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The low-energy image and the recombined

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images are what we see as radiologists.

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

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um, get sent to our workstation for imaging review.

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So what's excellent about contrast-enhanced

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mammography is that we get to combine what we know,

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which is information on morphology and density.

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And we get to combine that with information on

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enhancement, and we don't need an MRI to do it.

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It's all performed at the same time.

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This imaging modality, contrast-enhanced mammography,

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was actually approved over a decade ago at this point.

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Um, it was approved for use in

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the diagnostic setting in 2011.

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It's only really increased, um, throughout

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the country in the past few years.

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So let me show you, um, an

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example of a contrast mammogram.

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This was a 55-year-old woman who had a

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mass on her screening, and she was recalled

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and she had a diagnostic contrast-

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enhanced mammo.

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These are her low-energy images.

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Again, they look just like a 2D mammogram.

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Remember that, uh, the iodinated

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contrast has already been administered.

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There is already contrast within the breast.

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We just don't see it.

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So these are the low-energy images, and you can

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

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Can't really appreciate its margins that

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well, but then look at the recombined images.

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These are the images that show the enhancement.

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

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You can see the margins of the mass.

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

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It's heterogeneous, necrotic in the center.

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

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throughout the remaining aspect of that breast.

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So not only does it help us better classify

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what we're seeing, better understand

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it—or characterize it, I should say.

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It also helps exclude cancer

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in other portions of the breast.

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This is really great.

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This was a triple-negative breast cancer.