Contrast Enhanced Spectral Mammography (CESM) Initial UK Experience. Dr Sarah L Tennant BMedSci, BMBS, MRCP, FRCR

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1 Contrast Enhanced Spectral Mammography (CESM) Initial UK Experience Dr Sarah L Tennant BMedSci, BMBS, MRCP, FRCR

2 Vote Now Your experience of CESM 1. No experience of CESM 44% 2. I ve seen some cases in journals/at conferences 54% 3. I ve had to review CESM performed elsewhere in my routine practice 1% 4. I use CESM in my routine practice 1% 10

3 Which opinion most closely matches your views on CESM? 1. It s just poor man s MRI 11% 2. We don t have GE equipment, so it s not relevant to me 0% 3. I can see its potential 42% 4. I don t know enough about it to have an opinion Vote Now 47% 10

4 What is CESM? A relatively new technology Nottingham Breast Institute (NBI) is the first UK centre Essentially, a mammogram with the aid of contrast

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6 CESM - Physics Standard digital mammography might use Rh/Rh target/filter combination at 29 kvp K edge of iodine is 33.2keV A typical clinical concentration of iodine in the breast results in a low signal intensity, and is hardly distinguishable from the background

7 CESM - Physics CESM is based on dual-energy acquisitions 2 images acquired using distinct low-energy (LE standard mammography KV and filtration) and high-energy (HE higher KV with strong filtration) X-ray spectra The differences between X-ray attenuation of iodine and breast tissues at these two energy levels are exploited to suppress the background breast tissue

8 Typical LE and HE spectra used with Senobright and attenuation of breast tissue and iodine as a function of x-ray energy

9 CESM at NBI Introduction of a New Technology Local R&D team advice Classified as Service Evaluation providing written into departmental protocols Registered with local Audit and New Technologies committees Patient Information Sheet Consent Form

10 CESM at NBI Current Indications First-line imaging (instead of a standard digital mammogram) in symptomatic patients with a breast abnormality classified clinically as malignant in patients >35 years Second-line imaging (instead of a standard digital mammogram) in symptomatic patients <35 years with a malignant-appearing abnormality at ultrasound

11 CESM at NBI Practicalities Majority of patients will not have recent renal function/egfr Drew up specific criteria to exclude those patients at significant risk of contrastnephropathy

12 CESM at NBI Contra-indications Pregnancy Lactation Iodine allergy Renal failure Diabetic +/- on Metformin (unless recent, normal renal function available) Inability to give informed consent Inability to tolerate mammography Age >70 (specifically to reduce risk of contrast nephropathy)

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14 CESM at NBI Practicalities Warming cabinet Resus and anaphylaxis training Iopamidol 300, 100mls, through a pump injector at 3mls/sec No CRIS code we use XMCGB (old code for a breast pneumocystogram)

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16 Typical CESM Imaging Procedure for a bilateral breast examination with 2 views per breast

17 CESM at NBI So far so good We did our first case on 26 th November 2013 As of 7 th November 2014, we have performed 114 CESM examinations 1 contrast reaction No documented nephropathies 1 technical failure (wrong paddle) Audit ongoing but initial results promising excellent correlation with MRI and histology, and low false-positives

18 Case 1 30 Y F presents with a benign-feeling mass in the left breast (P3) Ultrasound performed as first-line imaging due to patient age This showed a solid lesion and 14g corebiopsy was obtained

19 Case 1 Core biopsy showed invasive carcinoma of no special type (NST), grade 2 MDT decision to offer CESM instead of standard digital mammogram for staging

20 Low Energy

21 Recombined Imaging The recently biopsied tumour in the left upper midline is seen as an enhancing mass measuring 21 mm. There is a second enhancing mass inferior to this in the left central breast, which measures 12mm. Total area to include both lesions is 40 mm. The right breast is within normal limits.

22 Case 1 Focussed ultrasound showed the second lesion, and ultrasoundguided core biopsy confirmed NST grade 2 tumour

23 Case 1 Mastectomy confirmed 2 well-defined tumour foci 19 and 13mm Associated multiple tumour foci with lobular features and vascular invasion Whole tumour size 35mm

24 Case 2 65 Y F Suspicious thickening right upper outer breast

25 Case 2 - Low energy MLOs

26 Case 2 - Low energy CCs

27 Case 2 Recombined MLOs

28 34mm avidly enhancing mass Case 2 Recombined CCs

29 Case 2 - Ultrasound

30 Case 3 Ultrasound-guided core biopsy - Grade 2 tumour of No Special Type (NST) Patient opted for WLE Invasive Carcinoma Size: 24 mm Whole tumour (DCIS + invasive carcinoma) size: 34 mm Localised, Grade 3, NST with lymphocyte rich stroma Had contralateral reduction too - all benign

31 Case 3 67 Y F Suspicious mass right breast centrally

32 Case 3 - Low energy MLOs

33 Case 3 - Low energy CCs

34 Case 3 Recombined MLOs

35 Case 3 Recombined CCs

36 A - 22mm enhancing mass B - 5mm enhancing mass Case 3 - Zoomed Case 3 Zoomed CC

37 Case 3 - Ultrasound Main lesion Second lesion

38 Case 3 - Ultrasound core biopsy Main lesion = Grade 2 tumour with lobular features Second lesion = NST, grade 1 Patient opted for mastectomy

39 Case 3 - Final histology - Mastectomy 2 distinct tumours A: pure special type lobular, Grade 2, 30mm B: NST, grade 1, 4mm

40 Case 4 25 Y Previously attended with benign-feeling change right breast Ultrasound-guided core of a vague area of reduced echo change came back as intermediate grade DCIS Mammogram required for accurate staging

41 Case 4 LE MLOs

42 Case 4 LE CCs

43 Case 4 LE MLO, zoomed and windowed

44 Case 4 Recombined MLOs

45 Case 4 Recombined CCs 48mm enhancement corresponding to faint calcification

46 Case 4 Attempt at WLE ultrasound wire guided 50mm HGDCIS with foci of micro invasion - margin <1mm Mastectomy and SNB performed no residual disease

47 Case 5 45 Y Suspicious mass right breast

48 Case 5 LE MLOs

49 Case 5 LE CCs

50 Case 5 Recombined MLOs

51 Case 5 Recombined CCs Eclipse sign of cyst, and faint nodular background enhancement in both breasts

52 Case 5 Ultrasound showed a simple cyst which was aspirated to dryness Patient reassured and discharged

53 Case 6 61 Y F Large ill defined mass right breast with skin tether and dimpling

54 Case 6 LE MLOs

55 Case 6 LE CCs

56 Case 6 Recombined MLOs

57 Case 6 Recombined CCs LE images show a spiculate mass in the central right breast but enhancement on the recombined images is more extensive - approx. 60mm

58 Case 6 MDT decision neoadjuvant chemotherapy Baseline MRI performed, as is current protocol

59 Case 6 CEMRI Axial Reformat

60 Case 6 CEMRI Sagittal Reformat The total size of abnormality at MRI is 55mm

61 Case 6 -Right recombined MLO vs Sagittal CEMRI Reformat

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63 The Pros Instant access performed in clinic Quick to perform and report Hangs well on PACS can scroll between low and recombined images Excellent correlation with MRI and pathological size increases radiologists confidence in accurately assessing local stage

64 The Cons Slows clinic down a little (mainly consenting process) Can t see as far back as on an MRI (chest wall lesions may be missed)

65 The Future? High-risk screening (dense breasts) Surveillance/follow-up Problem-solving/screening assessment Neoadjuvant response

66 Which opinion most closely matches your views on CESM now? 1. It s just poor man s MRI 10.8% 2. We don t have GE equipment, so it s not relevant to me 0.0% 3. I can see its potential 4. I don t know enough about it to have an opinion 2.0% Vote Now 87.3% 10

67 @drsarahtennant