Contrast Enhanced Spectral Mammography (CESM) Initial UK Experience Dr Sarah L Tennant BMedSci, BMBS, MRCP, FRCR
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
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
What is CESM? A relatively new technology Nottingham Breast Institute (NBI) is the first UK centre Essentially, a mammogram with the aid of contrast
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
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
Typical LE and HE spectra used with Senobright and attenuation of breast tissue and iodine as a function of x-ray energy
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
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
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
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)
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)
Typical CESM Imaging Procedure for a bilateral breast examination with 2 views per breast
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
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
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
Low Energy
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.
Case 1 Focussed ultrasound showed the second lesion, and ultrasoundguided core biopsy confirmed NST grade 2 tumour
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
Case 2 65 Y F Suspicious thickening right upper outer breast
Case 2 - Low energy MLOs
Case 2 - Low energy CCs
Case 2 Recombined MLOs
34mm avidly enhancing mass Case 2 Recombined CCs
Case 2 - Ultrasound
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
Case 3 67 Y F Suspicious mass right breast centrally
Case 3 - Low energy MLOs
Case 3 - Low energy CCs
Case 3 Recombined MLOs
Case 3 Recombined CCs
A - 22mm enhancing mass B - 5mm enhancing mass Case 3 - Zoomed Case 3 Zoomed CC
Case 3 - Ultrasound Main lesion Second lesion
Case 3 - Ultrasound core biopsy Main lesion = Grade 2 tumour with lobular features Second lesion = NST, grade 1 Patient opted for mastectomy
Case 3 - Final histology - Mastectomy 2 distinct tumours A: pure special type lobular, Grade 2, 30mm B: NST, grade 1, 4mm
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
Case 4 LE MLOs
Case 4 LE CCs
Case 4 LE MLO, zoomed and windowed
Case 4 Recombined MLOs
Case 4 Recombined CCs 48mm enhancement corresponding to faint calcification
Case 4 Attempt at WLE ultrasound wire guided 50mm HGDCIS with foci of micro invasion - margin <1mm Mastectomy and SNB performed no residual disease
Case 5 45 Y Suspicious mass right breast
Case 5 LE MLOs
Case 5 LE CCs
Case 5 Recombined MLOs
Case 5 Recombined CCs Eclipse sign of cyst, and faint nodular background enhancement in both breasts
Case 5 Ultrasound showed a simple cyst which was aspirated to dryness Patient reassured and discharged
Case 6 61 Y F Large ill defined mass right breast with skin tether and dimpling
Case 6 LE MLOs
Case 6 LE CCs
Case 6 Recombined MLOs
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
Case 6 MDT decision neoadjuvant chemotherapy Baseline MRI performed, as is current protocol
Case 6 CEMRI Axial Reformat
Case 6 CEMRI Sagittal Reformat The total size of abnormality at MRI is 55mm
Case 6 -Right recombined MLO vs Sagittal CEMRI Reformat
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
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)
The Future? High-risk screening (dense breasts) Surveillance/follow-up Problem-solving/screening assessment Neoadjuvant response
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
drsarahtennant@hotmail.com sarah.tennant@nuh.nhs.uk @drsarahtennant