CONTRAST ENHANCED SPECTRAL MAMMOGRAPHY

(CESM)

EXPERIENCE IN KUWAIT

Dr. EKI AGHAHOWADr. RANIA HEGAZYDr. RABAB YASINBREAST IMAGING UNIT OF RADIOLOGY DEPT.AL-JAHRA HOSPITALKUWAIT

DISCLOSURES

None.

OBJECTIVE

To describe the procedure of CESM and shareour initial experience from 15 prospectiveconsecutive cases done with a view ofshowing the usefulness of the procedure indiagnostic mammography and the learningcurve involved.

METHODFor image acquisition, we are using GE SenographeEssential with Senobrightupgrade .

After having ruled out any contraindication to I.V. iodinated contrast agent in the patient, using an Imaxeon automated injector, 1.5mls/kg Visapaque (Iodixamol) 320mg I/ml which has been warmed up to body temperature, is given at a flow rate of 3mls/sec.

TECHNIQUE

The low and high energy X-ray spectra in CESM are dependent on the K-edge of iodine. The K-edge of iodine is 33.2keV.

The low energy (LE) images are acquired using x-ray spectra for standarddigital mammography using Rh/Rh target/filter combination with tubevoltages (kVp) ranging from 26 to 30kVp which is below the K-edge ofiodine. The LE images look like the standard 2D digital mammogramimages and it is difficult to detect the iodinated contrast on them. Our LEimages were generated at 29kVp and 57 mAs.

The HE X-ray spectra contain energies above the K-edge of iodine, and sothe iodine attenuation is about 5.5 times more. This is obtained usingRh/Cu target/filter combination and tube voltages ranging from 45 to 49kVp. Our HE images were generated at 45kVp and 130 mAs. The HEimages have improved iodine detectability, but the breast tissue contrastis markedly deteriorated due to the high energy levels used.

There is a recombination algorithm in the system thatprocesses the LE and HE images such that the backgroundbreast tissue is suppressed to produce recombined imagesthat show only the iodine enhanced areas. Therecombination algorithm ensures visibility of 0.5mg/cm2

iodine areal concentration.

LE IMAGES9

HE IMAGES

RECOMBINED IMAGES

DCE-MRI

What the radiologist views towrite a report are the LE imagesand recombined images.

IMAGE INTERPRETATION

TYPE OF ENHANCEMENT OF THE LESION

MASS LIKE

• SHAPE

• MARGINS – Circumscribed, irregular, spiculate

• INTERNAL PATTERN – Homogenous, inhomogenous, ring

NON-MASS LIKE

• DISTRIBUTION – Diffuse, regional, segmental, ductal, multiple foci

INTENSITY OF ENHANCEMENT OF THE LESION

Nil

Mild

Moderate

Intense

CASE 177 yr old Kuwaiti woman with right breast mass of 2 yrs duration. No nipple discharge.

CASE 1 LE

CASE 1 RECOMBINED

CASE 1 US

CASE 1 CORE BIOPSY

Right invasive ductal Ca (grade 1) with foci ofin-situ Ca (cribriform type).

55yr old Egyptian lady with ?left breastmass. Erythema and induration of 2weeks duration in the LUOQ. Notenderness. No nipple discharge.

CASE 2

CASE 2 LE

CASE 2 RECOMBINED

CASE 2 US

CASE 2 DCE-MRI

CASE 2

Rec. CC DCE-MRI

MIP

Inflammatory smears rich in foamyhistiocytes and FB giant cells in necroticbackground. Negative for malignantcells. Suggestive of granulomatousmastitis.

CASE 2 CORE BIOPSY

CASE 3

55 yr old Jordanian lady presented withleft bloody nipple discharge. Positivefamily history of breast Ca (first degreerelative). Previous right lumpectomy in2000 for a benign lesion.

CASE 3 LE

CASE 3 RECOMBINED

CASE 3 US

CASE 3 US

CASE 3 US

CASE 3 DCE-MRI

MIP

Bilateral synchronous invasive ductalCa ----rt. multicentric and lt. multifocal with left axillary lymph node metastasis.

CASE 3 BILATERAL CORE BIOPSIES

CASE 4

50yr old Indian lady with right breast lump. ?Fibroadenoma

CASE 4 LE

CASE 4 RECOMBINED

CASE 4 US

CASE 4

Bilateral fibrocystic changes.

CASE 5 LE

CASE 5 RECOMBINED

CASE 6

81 yr old Kuwaiti woman with left breast mass. No nipple retraction.

CASE 6 LE

LMCC

CASE 6 RECOMBINED

CASE 6 US

Rec. CC CASE 6 DCE-MRI

MIP

CASE 6 CORE BIOPSY

Left multifocal invasive ductal Ca (NST) grade 2 with left axillary lymph node metastasis.

CASE 7

55 yr old non-Kuwaiti lady presented with leftmastalgia. Bilateral FFDM showed threemacrocalcifications in the RUOQ, two of whichwere dense and associated with a serpininoussoft tissue density suggestive of a blood vesselat 9 o’clock position in the right breast. Nohistory of previous trauma.

CASE 7 LE

CASE 7 RECOMBINED

CASE 7

Right lateral thoracic artery aneurysm with calcifications.

CASE 8

36yr old Indian lady with a 2 month history ofleft breast mass and left nipple retraction.

CASE 8 LE

CASE 8 RECOMBINED

CASE 8 DCE-MRI

CASE 8 CORE BIOPSY

Left invasive ductal Ca (grade 2) with left axillary lymph node metastases.

CASE 9

72 yr old Kuwaiti woman. Left breast mass was seen on CT abdomen.

CASE 9 LE

CASE 9 RECOMBINED

T1WI

STIR

DWI

ADC

CASE 9 MRI

CASE 9 DCE-MRI

CASE 9 CORE BIOPSY

Metastatic neuroendocrine Ca

CASE 9

Presented with 2 days history of diffuse abdominal pain, vomiting and diarrhoea. She had had 2 previous laparoscopies for abdominal pain in another hospital but there was no documentation available. Physicians made a diagnosis of gastroenteritis. DM,HTN, had partial hysterectomy for hyerplastic polyp and uterine fibroids in London 10 yrs ago.

NECT CASE 9 CECT

CONCLUSION

CESM is a useful tool in diagnostic mammography with reference to:

• Detecting or confirming multiplicity of lesions -multifocal/ multicentric/synchronous

• Can be done the same day as FFDM, as long as the radiologist has ruled out any contraindication to I.V. contrast administration for the patient and ensured that the patient has adequate renal function.

• It is a quick study – from start to finish is 7mins, but by five and a half minutes, you can be done.

• Useful for detecting masses in dense breasts.Radiologists should be aware of the learning curve involved.

THANK YOU