Download Contrast Enhanced Spectral Mammography (CESM) Initial UK

Contrast Enhanced Spectral
Mammography (CESM)
Initial UK Experience
Dr Sarah L Tennant
BMedSci, BMBS, MRCP, FRCR
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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
Vote Now
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
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 26th November 2013
• As of 7th 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
Case 2 – Recombined CCs
34mm avidly
enhancing mass
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
Case 3 - Zoomed
A - 22mm enhancing mass
B - 5mm enhancing mass
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
Vote Now
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
87.3%
4. I don’t know enough about it to have an
opinion
2.0%
10
[email protected]
[email protected]
@drsarahtennant