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Case 02

(continued)

Answer:

Subtle cancer on standard mammography can present as enhancing mass on recombined images.

This is an example of an invasive ductal cancer, triple positive, grade 2.
The cancer is presenting as architectural distortion on low -energy images and an enhancing mass on recombined images. These features are concerning for malignancy and biopsy is the recommended next step. Follow-up imaging, or returning the patient to screening is not appropriate. Breast MRI is not necessary. Biopsy is necessary before the area is localized for surgery.

CEM is great because we see DENSITY (whiteness) and MORPHOLOGY (shape) changes on the low-energy images (the images that look like a standard 2D mammogram) but we also get information on VASCULAR flow on the recombined images.

As cancer develops it recruits new blood vessels to increase blood flow to the area. We can see this increased blood flow, or vascularity, by giving contrast. These vascular areas show up very white from the contrast medium while the rest of the breast tissue that is less vascular is not as visible. For this reason, cancers can be very subtle on standard 2D imaging but very apparent on the recombined images. But non-cancers can also take up the contrast agent so often we need to biopsy in order to figure out the exact process.

Perry H, Phillips J, Dialani V, Slanetz PJ, et al. Contrast-Enhanced Mammography: A Systematic Guide to Interpretation and Reporting. AJR Am J Roentgenol. 2019 Jan;212(1):222-231.

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