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DOI: 10.1055/s-0042-1760321
Contrast Enhanced Mammography Descriptors using Breast Imaging and Reporting and Data System
- Abstract
- Introduction
- Technique
- ACR BIRADS Contrast-Enhanced Mammography Lexicon
- Associated features (Fig. 20)
- Lesion Location
- Report Organization
- Conclusion
- References
Abstract
Contrast-enhanced mammography (CEM) is an emerging breast imaging technique with a potential to develop into a one-stop imaging solution for several conditions which require imaging, especially its role in cancer detection and local staging when combined with ultrasound. In 2022, CEM lexicon was published as a supplement to the American College of Radiology Breast Imaging Reporting and Data System (ACR BIRADS) fifth edition. This pictorial review illustrates the findings that are seen on CEM using ACR BIRADS CEM lexicon to make the reader familiar with the terminologies. In our experience, interpretation and description of findings in CEM using ACR-BIRADS CEM lexicon had a short learning curve and it was easy to implement in practice as most of the terminologies were already in use for interpreting magnetic resonance imaging.
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Keywords
contrast-enhanced mammography reporting - ACR BIRADS CEM lexicon - breast cancer - recombined imagesIntroduction
Contrast-enhanced mammography (CEM) is an emerging breast imaging technique which has wide applications. Though it was approved by the Food and Drug Administration in 2011, it remained underutilized until recently. In recent years, the number of published research studies on CEM has increased and these results show that CEM has sensitivity on par with dynamic contrast-enhanced magnetic resonance imaging (MRI) for cancer detection.[1] [2]
ACR BIRADS MRI lexicon was used to describe findings in CEM.[3] [4] In early 2022, CEM lexicon was published as a supplement to ACR BIRADS fifth edition.[3] In this review, we present a pictorial presentation of findings on CEM using ACR BIRADS CEM lexicon to make the readers familiar with findings in CEM and guide them to apply correct terminologies while reading CEM.
All the CEM images presented in this review were acquired using the Hologic 3 Dimensions mammography system at our institution.
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Technique
After 1.5 mL/kg injection of intravenous iodinated contrast medium, low-energy (28–31 kVp) and high-energy (45–49 kVp) images of two standard views of each breast are acquired during single compression. Low-energy images serve as conventional 2D mammography images. High-energy images are not interpretable. Low- and high-energy images are postprocessed to produce recombined images (RC images) which contain contrast information.
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ACR BIRADS Contrast-Enhanced Mammography Lexicon
Breast Composition
This is assessed in low-energy images like conventional mammography. One of the following descriptors are used.
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a. Almost entirely fatty.
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b. Scattered fibroglandular density.
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c. Heterogeneously dense.
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d. Extremely dense.
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Background Parenchymal Enhancement
Background parenchymal enhancement denotes normal enhancement of the patient's fibroglandular tissue ([Fig. 1]). However, it may not be directly related to the amount of fibro-glandular tissue. The background parenchymal enhancement is progressive over time, and thus, the background parenchymal enhancement (BPE) is assessed at first postcontrast image. At our institution, we routinely take craniocaudal (CC) views of both breasts first followed by mediolateral oblique views. So, we describe the BPE in CC views as minimal, mild, moderate, or marked ([Table 1]).
Background parenchymal enhancement |
1. Level |
a. Minimal b. Mild c. Moderate d. Marked |
2. Symmetric/asymmetric |
a. Symmetric b. Asymmetric |
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BPE is an important component in the interpretation of CEM because the presence of moderate to marked background parenchymal enhancement reduces the sensitivity of CEM. Further, available evidence shows that BPE is an independent predictor of breast cancer risk.[5]
In MRI, it is recommended to schedule elective examinations at the 2nd week of the menstrual cycle when the BPE will be less. But several studies have shown that the outcome may not be affected by the time of menstrual cycle. There are little data about timing the CEM at a particular phase of the menstrual cycle.
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Findings
The findings on CEM are divided into three broad categories.
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These are the abnormalities which are seen on low-energy images without enhancement in RC images. These are described using the ACR BIRADS mammography lexicon.[3]
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B. Enhancement in RC images only without low-energy correlate:
Based on the enhancing morphology, these findings may be described as, mass, nonmass enhancement (NME), or enhancing asymmetry ([Table 2]). The descriptors for enhancing findings in CEM are similar to MRI. Few MRI descriptors like focus are not used in CEM lexicon because of the inherent low resolution of CEM. An additional descriptor specific to CEM is lesion conspicuity ([Fig. 4]).
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Abbreviation: RC, recombined images.
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A mass is a 3-dimensional space occupying lesion with convex outer margins. The descriptors for mass are margins, shape, and internal enhancement characteristics.
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1. Shape.
The shape of the mass can be oval, round, or irregular. If the lesion is elliptical or egg shaped, it is called an oval lesion and it may include two to three lobulations. When the lesion is spherical, ball shaped, circular, or globular, it is a round lesion. When the shape of the lesion is neither round nor oval, it is called irregular. Irregular shape implies a suspicious finding.[6]
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2. Margins.
The margin is the edge or border of the lesion. Margins describe the behavior of the mass with the surrounding tissue. Margins can be circumscribed or noncircumscribed.
The margin is called circumscribed if it is sharply demarcated and has an abrupt transition with the surrounding tissue. It is important to note that the entire margin of the mass should be sharply demarcated to describe it as circumscribed. If any portion of the margin is not circumscribed, it should be classified based on the most suspicious finding. Masses with noncircumscribed margins are subclassified into irregular or spiculated margins. When the edges are uneven or jagged it is called irregular. Spiculated margins are characterized by radiating lines from the edges. Both irregular and spiculated margins imply that the findings are suspicious.[4]
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3. Internal enhancement characteristics.
Internal enhancement describes the enhancement pattern within a mass. The three types of internal enhancement patterns in CEM are homogeneous, heterogeneous, and rim enhancement.
It is homogeneous ([Fig. 5]) when there is confluent uniform enhancement. Heterogeneous ([Fig. 6]) enhancement is nonuniform enhancement of the mass. When the enhancement is more pronounced at the periphery of the mass, it is called rim enhancement, and it implies a suspicious finding especially when the enhancing rim is nodular and irregular.
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II. Nonmass Enhancement
NME is defined as an enhancing area that is neither a mass nor a focus. It does not have convex outer margins and may have intervening fat or fibroglandular tissue. NME is described in terms of distribution and internal enhancement pattern.
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Distribution ([Figs. 7] and [8])
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Focal—occupies less than one quadrant of breast volume.
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Linear—enhancement arranged in a line or a line of enhancement that branches. Linear NME is a suspicious finding because it represents ductal abnormality.
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Segmental—triangular- or cone-shaped enhancement with its apex pointing to the nipple. Segmental NME is a suspicious finding because it represents enhancement along the duct and its branches involving one lobe.[7]
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Regional—when the NME involves more than one quadrant, it is called regional NME.
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Multiple regions—enhancement in at least two large volumes of tissues separated by normal tissue.
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Diffuse—enhancement throughout the breast.
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Internal enhancement pattern ([Fig. 9])
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III. Enhancing asymmetry ([Fig. 10]):
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For enhancing findings which are seen in one view only, the term “enhancing asymmetry” is introduced in CEM lexicon. If asymmetry is seen in conventional mammogram which exhibit enhancement, it can also be described as enhancing asymmetry.
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IV. Conspicuity of the lesion:
Conspicuity of the lesion denoting the degree of enhancement relative to the BPE may be described as low, moderate, or high ([Fig. 4]). Low conspicuity is enhancement equal to or slightly greater than BPE. High conspicuity is used when the enhancement is much greater than BPE. Moderate conspicuity is the enhancement between the low and high conspicuity.
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C. Findings seen on low-energy images with associated enhancement in RC images.
The morphologic characteristics of the findings (mass, asymmetries, architectural distortion, and calcifications) are described from the low-energy images using the ACR- BIRADS mammography lexicon. For mass lesions ([Figs. 11],[12],[13],[14],[15],[16]), shape, margins, and density are described from low-energy images and enhancement patterns are described from the RC images. For all other abnormalities (asymmetries, architectural distortion [[Fig. 17]] and calcifications [[Fig. 18]]), the characteristics of enhancement are described using the CEM lexicon. For example, if an architectural distortion shows enhancement, it should be described as mass/NME based on the appearance in RC images. Further, if it has a morphology of mass, it should be described in terms of shape, margins, and internal enhancement pattern. If it is an NME, distribution and internal enhancement pattern descriptors should be used.
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Other descriptors on RC images for the lesions seen on both low energy and RC image include the following factors.
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1. Extent of enhancement ([Fig. 19]):
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This descriptor denotes the extent of enhancement relative to the size of the abnormality in a low-energy image. It is described using four categories
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(a) Partial enhancement of the mammographic lesion.
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(b) Complete enhancement of the mammographic lesion.
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(c) Enhancement beyond the mammographic lesion.
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(d) No enhancement.
Lesions which do not show enhancement are more likely to be benign.
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2. Lesion conspicuity: Low, moderate, or high as described earlier.
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Associated features ([Fig. 20])
These findings are generally seen in low-energy images but can be appreciated in RC images also. These are
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(a) Nipple retraction
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(b) Nipple invasion
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(c) Skin thickening
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(d) Skin invasion
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(e) Skin retraction
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(f) Trabecular thickening
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(g) Axillary adenopathy.
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Lesion Location
Like mammography, the location is described in terms of side, followed by quadrant, clock-face orientation and depth (anterior, middle, or posterior third).
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Report Organization
CEM includes both low-energy and RC image components. So in the report, BIRADS assessment and management should incorporate findings from both the components.
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Conclusion
In this pictorial review, we presented findings in CEM using ACR BIRADS CEM lexicon to make the readers familiar with the findings in CEM and terminologies in CEM lexicon. In our experience interpretation and description of enhancing findings in CEM using ACR-BIRADS CEM lexicon had a quick learning curve, it was easy to implement in practice as most of the terminologies were already in use for interpreting MRI.
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Conflict of Interest
None declared.
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References
- 1 Zanardo M, Cozzi A, Trimboli RM. et al. Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review. Insights Imaging 2019; 10 (01) 76
- 2 Sumkin JH, Berg WA, Carter GJ. et al. Diagnostic performance of MRI, molecular breast imaging, and contrast-enhanced mammography in women with newly diagnosed breast cancer. Radiology 2019; 293 (03) 531-540
- 3 D'Orsi CJ, Sickles EA, Mendelson EB. et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013
- 4 Kamal RM, Helal MH, Mansour SM. et al. Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography?. Br J Radiol 2016; 89 (1064): 20160157
- 5 Sogani J, Morris EA, Kaplan JB. et al. Comparison of background parenchymal enhancement at contrast-enhanced spectral mammography and breast MR imaging. Radiology 2017; 282 (01) 63-73
- 6 Gity M, Arabkheradmand A, Taheri E, Shakiba M. Diagnostic investigation of breast magnetic resonance imaging in malignant and benign mass lesions. Arch Med Sci 2018; 14 (05) 1061-1069
- 7 Yang QX, Ji X, Feng LL. et al. Significant MRI indicators of malignancy for breast non-mass enhancement. J XRay Sci Technol 2017; 25 (06) 1033-1044
- 8 Lee SM, Nam KJ, Choo KS. et al. Patterns of malignant non-mass enhancement on 3-T breast MRI help predict invasiveness: using the BI-RADS lexicon fifth edition. Acta Radiol 2018; 59 (11) 1292-1299
Address for correspondence
Publication History
Article published online:
19 September 2023
© 2022. Indographics. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
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References
- 1 Zanardo M, Cozzi A, Trimboli RM. et al. Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review. Insights Imaging 2019; 10 (01) 76
- 2 Sumkin JH, Berg WA, Carter GJ. et al. Diagnostic performance of MRI, molecular breast imaging, and contrast-enhanced mammography in women with newly diagnosed breast cancer. Radiology 2019; 293 (03) 531-540
- 3 D'Orsi CJ, Sickles EA, Mendelson EB. et al. ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013
- 4 Kamal RM, Helal MH, Mansour SM. et al. Can we apply the MRI BI-RADS lexicon morphology descriptors on contrast-enhanced spectral mammography?. Br J Radiol 2016; 89 (1064): 20160157
- 5 Sogani J, Morris EA, Kaplan JB. et al. Comparison of background parenchymal enhancement at contrast-enhanced spectral mammography and breast MR imaging. Radiology 2017; 282 (01) 63-73
- 6 Gity M, Arabkheradmand A, Taheri E, Shakiba M. Diagnostic investigation of breast magnetic resonance imaging in malignant and benign mass lesions. Arch Med Sci 2018; 14 (05) 1061-1069
- 7 Yang QX, Ji X, Feng LL. et al. Significant MRI indicators of malignancy for breast non-mass enhancement. J XRay Sci Technol 2017; 25 (06) 1033-1044
- 8 Lee SM, Nam KJ, Choo KS. et al. Patterns of malignant non-mass enhancement on 3-T breast MRI help predict invasiveness: using the BI-RADS lexicon fifth edition. Acta Radiol 2018; 59 (11) 1292-1299
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