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      Contrast-enhanced spectral mammography (CESM)-guided breast biopsy as an alternative to MRI-guided biopsy

      1 ,
      The British Journal of Radiology
      The British Institute of Radiology.

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          Contrast-enhanced spectral mammography (CESM) breast biopsy has been recently introduced into clinical practice. This short communication describes the technique and potential as an alternative to MRI-guided biopsy.

          Methods and materials:

          An additional abnormality was detected on a breast MRI examination in a patient with lobular carcinoma. The lesion was occult on conventional mammography, tomosynthesis and ultrasound and required histological diagnosis. Traditionally, this would have necessitated an MRI-guided breast biopsy, but was performed under CESM guidance.


          A diagnostic CESM study was performed to ensure the lesion visibility with CESM and then targeted under CESM guidance. A limited diagnostic study, CESM scout and paired images for stereotactic targeting were obtained within a 10 min window following a single injection of iodinated contrast agent. The time from positioning in the biopsy device to releasing compression after biopsy and marker clip placement was 15 min. The biopsy confirmed the presence of multifocal breast cancer.


          CESM-guided breast biopsy is a new technique that can be successfully used as an alternative to MRI-guided breast biopsy.

          Advances in knowledge:

          CESM-guided biopsy can be used to sample breast lesions which remain occult on standard mammography and ultrasound.

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          Most cited references11

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          Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer.

          PURPOSE We review the evidence on magnetic resonance imaging (MRI) in staging the affected breast to determine its accuracy and impact on treatment. METHODS Systematic review and meta-analysis of the accuracy of MRI in detection of multifocal (MF) and/or multicentric (MC) cancer not identified on conventional imaging. We estimated summary receiver operating characteristic curves, positive predictive value (PPV), true-positive (TP) to false positive (FP) ratio, and examined their variability according to quality criteria. Pooled estimates of the proportion of women whose surgery was altered were calculated. Results Data from 19 studies showed MRI detects additional disease in 16% of women with breast cancer (N = 2,610). MRI incremental accuracy differed according to the reference standard (RS; P = .016) decreasing from 99% to 86% as the quality of the RS increased. Summary PPV was 66% (95% CI, 52% to 77%) and TP:FP ratio was 1.91 (95% CI, 1.09 to 3.34). Conversion from wide local excision (WLE) to mastectomy was 8.1% (95% CI, 5.9 to 11.3), from WLE to more extensive surgery was 11.3% in MF/MC disease (95% CI, 6.8 to 18.3). Due to MRI-detected lesions (in women who did not have additional malignancy on histology) conversion from WLE to mastectomy was 1.1% (95% CI, 0.3 to 3.6) and from WLE to more extensive surgery was 5.5% (95% CI, 3.1 to 9.5). CONCLUSION MRI staging causes more extensive breast surgery in an important proportion of women by identifying additional cancer, however there is a need to reduce FP MRI detection. Randomized trials are needed to determine the clinical value of detecting additional disease which changes surgical treatment in women with apparently localized breast cancer.
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            Contrast-enhanced spectral mammography (CESM) and contrast enhanced MRI (CEMRI): Patient preferences and tolerance.

            Contrast-enhanced spectral mammography (CESM) may have similar diagnostic performance to Contrast-enhanced MRI (CEMRI) in the diagnosis and staging of breast cancer. To date, research has focused exclusively on diagnostic performance when comparing these two techniques. Patient experience is also an important factor when comparing and deciding on which of these modalities is preferable. The aim of this study is to compare patient experience of CESM against CEMRI during preoperative breast cancer staging.
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              Magnetic resonance imaging in the preoperative assessment of patients with primary breast cancer: systematic review of diagnostic accuracy and meta-analysis.

              To estimate the diagnostic accuracy of magnetic resonance imaging (MRI) in detecting additional lesions and contralateral cancer not identified using conventional imaging in primary breast cancer. We have conducted a systematic review and meta-analyses to estimate diagnostic accuracy indices and the impact of MRI on surgical management. Fifty articles were included (n = 10,811 women). MRI detected additional disease in 20% of women and in the contralateral breast in 5.5%. The summary PPV of ipsilateral additional disease was 67% (95% CI 59-74%). For contralateral breast, the PPV was 37% (95% CI 27-47%). For ipsilateral lesions, MRI devices ≥1.5 Tesla (T) had higher PPV (75%, 95% CI 64-83%) than MRI with <1.5 T (59%, 95% CI 53-71%). Similar results were found for contralateral cancer, PPV 40% (95% CI 29-53%) and 19% (95% CI 8-39%) for high- and low-field equipments, respectively. True positive MRI findings prompted conversion from wide local excision (WLE) to more extensive surgery in 12.8% of women while in 6.3% this conversion was inappropriate. MRI shows high diagnostic accuracy, but MRI findings should be pathologically verified because of the high FP rate. Future research on this emerging technology should focus on patient outcome as the primary end-point.

                Author and article information

                Br J Radiol
                Br J Radiol
                The British Journal of Radiology
                The British Institute of Radiology.
                01 April 2022
                20 January 2022
                20 January 2022
                : 95
                : 1132
                : 20211287
                [1 ]org-divisionNottingham Breast Institute, Nottingham University Hospitals , Nottingham, UK
                Author notes
                Address correspondence to: Dr Jonathan James. E-mail: jonathan.james@ 123456nuh.nhs.uk
                © 2022 The Authors. Published by the British Institute of Radiology

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 Unported License http://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted non-commercial reuse, provided the original author and source are credited.

                : 22 November 2021
                : 21 December 2021
                : 30 December 2021
                Page count
                Figures: 5, Tables: 0, Equations: 0, References: 11, Pages: 5, Words: 3144
                Short Communication
                bjr, BJR
                int-vasc, Interventional and Vascular
                brst, Breast
                oth, Other

                Radiology & Imaging
                Radiology & Imaging


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