False-Positive and False-Negative Contrast-enhanced Mammograms: Pitfalls and Strategies to Improve Cancer Detection.

Contrast-enhanced mammography (CEM) is a relatively new breast imaging modality that uses intravenous contrast material to increase detection of breast cancer. CEM combines the structural information of conventional mammography with the functional information of tumor neovascularity. Initial studies have demonstrated that CEM and MRI perform with similar accuracies, with CEM having a slightly higher specificity (fewer false positives), although larger studies are needed. There are various reasons for false positives and false negatives at CEM. False positives at CEM can be caused by benign lesions with vascularity, including benign tumors, infection or inflammation, benign lesions in the skin, and imaging artifacts. False negatives at CEM can be attributed to incomplete or inadequate visualization of lesions, marked background parenchymal enhancement (BPE) obscuring cancer, lack of lesion contrast enhancement due to technical issues or less-vascular cancers, artifacts, and errors of lesion perception or characterization. When possible, real-time interpretation of CEM studies is ideal. If additional views are necessary, they may be obtained while contrast material is still in the breast parenchyma. Until recently, a limitation of CEM was the lack of CEM-guided biopsy capability. However, in 2020, the U.S. Food and Drug Administration cleared two devices to support CEM-guided biopsy using a stereotactic biopsy technique. The authors review various causes of false-positive and false-negative contrast-enhanced mammograms and discuss strategies to reduce these diagnostic errors to improve cancer detection while mitigating unnecessary additional imaging and procedures. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Imaging Characteristics of and Multidisciplinary Management Considerations for Atypical Ductal Hyperplasia and Flat Epithelial Atypia: Review of Current Literature.

High-risk lesions of the breast are frequently encountered in percutaneous biopsy specimens. While benign, these lesions have historically undergone surgical excision due to their potential to be upgraded to malignancy. However, there is emerging evidence that a tailored management approach should be considered to reduce overtreatment of these lesions. Flat epithelial atypia (FEA) and atypical ductal hyperplasia (ADH) are two of the most commonly encountered high-risk lesions. FEA has been shown to have a relatively low rate of progression to malignancy, and some guidelines are now recommending observation over routine excision in select cases. Selective observation may be reasonable in cases where the target lesion is small and completely removed at biopsy and when there are no underlying risk factors, such as a history of breast cancer or genetic mutation or concurrent ADH. ADH has the highest potential upgrade rate to malignancy of all the high-risk lesions. Most society guidelines continue to recommend surgical excision of this lesion. More recently, some literature suggests that ADH lesions that appear completely removed at biopsy, involve limited foci (less than two or three) with no necrosis or significant atypia, manifest as a small group of mammographic calcifications, or demonstrate no enhancement at MRI may be reasonable for observation. Ultimately, management of all high-risk lesions must be based on a multidisciplinary approach that considers all patient, radiologic, clinical, and histopathologic factors. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Contrast-Enhanced Mammography for Newly Diagnosed Breast Cancer in Women With Breast Augmentation: Preliminary Findings.

In 17 women with newly diagnosed breast cancer who underwent contrast-enhanced mammography (CEM) and MRI, both modalities were found to be concordant for the index cancer. In six of the 17 women, CEM showed an additional lesion that was confirmed by MRI. Of these six additional lesions, three were multifocal, one was multicentric, and two were contralateral; two of the six were malignant. MRI did not identify any additional cancers that were not identified on CEM. CEM may have a role in women with breast augmentation and either a contraindication or limited access to MRI.

Contrast-enhanced Mammography: How Does It Work?

Contrast-enhanced mammography (CEM) is an imaging technique that uses iodinated contrast medium to improve visualization of breast lesions and assessment of tumor neovascularity. Through modifications in x-ray energy, high- and low-energy images of the breast are combined to highlight areas of contrast medium pooling. The use of contrast material introduces different workflows, artifacts, and risks related to the contrast medium dose. In addition, the need to acquire multiple images in each view introduces different workflows, artifacts, and risks associated with the radiation dose. Although CEM and conventional mammography share many underlying principles, it is important to understand how these two mammographic examinations differ and the mechanisms that facilitate image contrast at CEM. ©RSNA, 2021.

Prospective Study of Supplemental Screening With Contrast-Enhanced Mammography in Women With Elevated Risk of Breast Cancer: Results of the Prevalence Round.

PURPOSE: Contrast-enhanced mammography (CEM) and magnetic resonance imaging (MRI) have shown similar diagnostic performance in detection of breast cancer. Limited CEM data are available for high-risk breast cancer screening. The purpose of the study was to prospectively investigate the efficacy of supplemental screening CEM in elevated risk patients. MATERIALS AND METHODS: A prospective, single-institution, institutional review board-approved observational study was conducted in asymptomatic elevated risk women age 35 years or older who had a negative conventional two-dimensional digital breast tomosynthesis screening mammography (MG) and no additional supplemental screening within the prior 12 months. RESULTS: Four hundred sixty women were enrolled from February 2019 to April 2021. The median age was 56.8 (range, 35.0-79.2) years; 408 of 460 (88.7%) were mammographically dense. Biopsy revealed benign changes in 22 women (22/37, 59%), high-risk lesions in four women (4/37, 11%), and breast cancer in 11 women (11/37, 30%). Fourteen cancers (10 invasive, tumor size range 4-15 mm, median 9 mm) were diagnosed in 11 women. The overall supplemental cancer detection rate was 23.9 per 1,000 patients, 95% CI (12.0 to 42.4). All cancers were grade 1 or 2, ER+ ERBB2-, and node negative. CEM imaging screening offered high specificity (0.875 [95% CI, 0.844 to 0.906]), high NPV (0.998 [95% CI, 0.993 to 1.000), moderate PPV1 (0.164 [95% CI, 0.076 to 0.253), moderate PPV3 (0.275 [95% CI, 0.137 to 0.413]), and high sensitivity (0.917 [95% CI, 0.760 to 1.000]). At least 1 year of imaging follow-up was available on all patients, and one interval cancer was detected on breast MRI 4 months after negative screening CEM. CONCLUSION: A pilot trial demonstrates a supplemental cancer detection rate of 23.9 per 1,000 in women at an elevated risk for breast cancer. Larger, multi-institutional, multiyear CEM trials in patients at elevated risk are needed for validation.

Acquired cystic disease subtype renal cell carcinoma (ACD-RCC): prevalence and imaging features at a single institution.

PURPOSE: Acquired cystic kidney disease (ACKD) is commonly seen in patients with end-stage renal disease (ESRD), and patients with ACKD have an increased risk of renal cell carcinoma (RCC). Acquired cystic disease-associated RCC (ACD-RCC) was incorporated into the 2016 World Health Organization Classification. This study aims to describe the imaging features of ACD-RCC, which are not well reported previously. METHODS: Retrospective review of patients with ACKD who underwent total nephrectomy for concern of a renal mass between 2016 and 2021 yielded 122 nephrectomies in 107 patients. Pathology reports were searched for type and subtype of mass. In ACD-RCC subtypes, imaging studies were evaluated for modality and contrast enhancement (CE). Imaging findings assessed included cystic/solid nature, unenhanced CT (NECT) attenuation, enhancement characteristics [non-enhancing (< 10 HU difference), equivocal (10-20 HU), enhancing (> 20 HU)], subjective MRI enhancement, T1 and T2 signal intensity, restricted diffusion, ultrasound (US) echogenicity, and subjective CEUS enhancement. RESULTS: 148 masses were identified, 122 (82%) of which were malignant and 26 (18%) benign. The three most common tumors were clear cell RCC (n = 47), papillary RCC (n = 35), and ACD-RCC (n = 21). Of the 21 cases of ACD-RCC, 16 had preoperative imaging: CT (15: 6 NECT only, 2 CECT only, 7 combined NECT and CECT), MRI (4), CEUS (5). Ten of these tumors were solid/mostly solid and 6 mixed cystic/solid. On NECT, the average attenuation was 35 HU (range 13-52). Of those with multiphasic CTs, 1 was non-enhancing, 3 were equivocal, and 3 enhanced. All 3 masses imaged with CE-MRI showed enhancement. All 4 tumors evaluated by MRI demonstrated T2 hypointensity and restricted diffusion. All five masses enhanced on CEUS. CONCLUSION: ACD-RCC subtype was the third most common renal neoplasm in ACKD patients. Our findings found that no single imaging feature is pathognomonic for ACD-RCC. However, ACD-RCCs are typically solid masses with most demonstrating equivocal or mild enhancement on CT. T2 hypointensity and restricted diffusion were the most common MRI features.

Women's Experience With Screening Mammography During the COVID-19 Pandemic: A Multi-Institutional Prospective Survey Study.

OBJECTIVE: Evaluate women's anxiety and experience undergoing screening mammography during the COVID-19 pandemic. METHODS: An IRB-approved anonymous survey was administered to women receiving screening mammography across six sites in the U.S. and Singapore from October 7, 2020, to March 11, 2021. Using a 1-5 Likert scale, women rated their pre- and post-visit anxiety regarding having their mammogram during the COVID-19 pandemic, importance of observed COVID-19 precautions, and personal risk factors for breast cancer and severe COVID-19 illness. Post-visit change in anxiety was evaluated. Multivariable logistic regression was used to test associations of pre-visit anxiety with breast cancer and COVID-19 risk factors. RESULTS: In total, 1086 women completed the survey. Of these, 59% (630/1061) had >1 breast cancer risk factor; 27% (282/1060) had >1 COVID-19 risk factors. Forty-two percent (445/1065) experienced pre-visit anxiety. Pre-visit anxiety was independently associated with risk factors for severe COVID-19 (OR for >2 vs 0 risk factors: 2.04, 95% confidence interval [CI]: 1.11-3.76) and breast cancer (OR for >2 vs 0 risk factors: 1.71, 95% CI: 1.17-2.50), after adjusting for age and site. Twenty-six percent (272/1065) of women reported post-visit anxiety, an absolute 16% decrease from pre-visit anxiety (95% CI: 14%-19%, P < 0.001). Provider masking (941/1075, 88%) and physical distancing (861/1085, 79%) were rated as the most important precautions. CONCLUSION: Pre-visit anxiety was associated with COVID-19 or breast cancer risk factors and declined significantly after screening mammography. Provider masking and physical distancing were rated the most important precautions implemented by imaging clinics.

Concurrent Liver and Mesentery Primary Extraosseous Multiple Myeloma on 18F-FDG PET/CT.

ABSTRACT: Extramedullary multiple myeloma (EMM) is a subset of multiple myeloma with a poor prognosis. We report a rare case with biopsy-proven concurrent liver and mesentery primary EMM at the time of initial staging after serologic diagnosis of multiple myeloma. 18F-FDG PET/CT is valuable in detection of EMM when the patient has no osseous lesions and a negative bone marrow biopsy.

Demonstration of 99mTc-MDP Uptake in a Mobile Urinary Bladder Calculus on SPECT/CT.

We report a large mobile bladder calculus with intense Tc-MDP uptake demonstrated on both whole-body bone scintigraphy and SPECT/CT images in a patient with complicated chronic history of urolithiasis and urinary tract infection. Bone tracer uptake in bladder calculus is a rare phenomenon and might be related to the composition and matrix of calculus, direct exposure to excreted radiotracer, and bacterial colonization on the surface of calculus.