Contrast-Enhanced Mammography

Contrast-enhanced mammography (CEM) is a new breast imaging technique that combines a traditional mammogram with iodinated contrast dye (the same dye that is used for CT scans). The dye collects in abnormal blood vessels, making it possible to see breast cancers and other lesions that would otherwise not be visible on the mammogram.

Above this column is an example: two images of the same breast, on the same day. A traditional mammogram is on the left: the cancer is not visible. A “recombined” CEM image on the right is not limited by the dense tissue and highlights the cancer (arrow).

Who could benefit from a contrast-enhanced mammogram?

CEM is U.S. Food and Drug Administration-approved as a diagnostic tool for further evaluation of possible or known breast abnormalities. However, centers such as Memorial Sloan Kettering and a recent paper in “The Lancet” have shown significant benefits in using CEM “off-label.” Screening CEM can be considered for all women with dense breasts, especially if they:

• Have extremely dense breasts
• Have complex dense patterns (for example, many cysts)
• Should be having breast MRI but cannot or are not (“high risk”)
• Are calculated to be at intermediate risk for breast cancer (using the Tyrer-Cuzick Risk Assessment Calculator)
• Are breast cancer survivors, especially if they were younger than 50 years old at the time of diagnosis

What is involved in having a CEM study?

Prior to the CEM exam, the patient will be screened to make sure she can safely have a CEM exam. On the day of the study, an IV will be placed (arm or hand) and a dose of iodinated CT contrast is administered. After a short delay, the positioning and compression of the breast are the same as for a standard digital mammogram. The images are typically read while the patient is still at the imaging center, providing immediate results.

How does CEM compare to whole breast ultrasound, breast MRI, and tomosynthesis (3D mammogram)?

CEM has been shown to find three to five times more breast cancers than breast ultrasound. CEM detects nearly as many breast cancers as breast MRI, but CEM has fewer false positives (false alarms) than breast MRI, and most patients find CEM to be much more comfortable than breast MRI. CEM and tomosynthesis (3D) can be performed together at the same time; if an abnormality is identified, this “combo” exam can help with biopsy targeting.

What are the downsides of CEM?

CEM does add some radiation, but the amounts are still within the accepted safety range for mammography. There is a risk of an adverse reaction to the contrast (same as with a CT scan). And “off-label” screening CEM is not yet covered by insurance.

Who should not have CEM?

Women who are pregnant, have uncontrolled kidney disease, or are allergic to iodine-based contrast should not have CEM.

What happens if CEM shows a highlighted area?

If a possible abnormality is identified, about one-third of the time, a correlate can be found on ultrasound. If needed, CEM-guided biopsy can be performed.

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