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Case 10

(continued)

Answer:

CEM can be used to determine disease extent.

In this patient, a CEM was performed in lieu of an MRI. The value of CEM is to show the size of tumor and identify for any obvious ipsilateral or contralateral disease.

Many studies have compared CEM to breast MRI to determine disease extent and have found that CEM has similar diagnostic accuracy to breast MRI. MRI has been shown to find a few more ipsilateral and contralateral cancers, but with many more false positives. For this reason, many clinicians PREFER CEM over MRI. Although it may find a few less cancers, it has far fewer false positives, reducing the number of unnecessary biopsies performed for these women.

Tumor size should include any abnormal on low-energy or recombined-images. For this reason, non-enhancing suspicious areas should be included in the disease extent. Unfortunately, CEM is similar to standard mammography and does not capture the full axilla. To fully evaluate the axilla -- if your institutions/practice does this -- then ultrasound would be the preferred method. As of now, CEM is not able to predict tumor subtype, but research on this is underway.

Jochelson MS, Dershaw DD, Sung JS, et al. Bilateral contrast-enhanced dual-energy digital mammography: feasibility and comparison with conventional digital mammography and MR imaging in women with known breast carcinoma. Radiology. 2013 Mar;266(3):743-51.

Lobbes MBI, Heuts EM, Moossdorff M, van Nijnatten TJA. Contrast enhanced mammography (CEM) versus magnetic resonance imaging (MRI) for staging of breast cancer: The pro CEM perspective. Eur J Radiol. 2021 Sep;142:109883.

Sumkin JH, Berg WA, Carter GJ, et al. Diagnostic Performance of MRI, Molecular Breast Imaging, and Contrast-enhanced Mammography in Women with Newly Diagnosed Breast Cancer. Radiology. 2019 Dec;293(3):531-540.

Fallenberg EM, Schmitzberger FF, et al. Contrast-enhanced spectral mammography vs. mammography and MRI - clinical performance in a multi-reader evaluation. Eur Radiol. 2017 Jul;27(7):2752-2764.

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