How the test is performed
The procedure is performed using an intravenous iodine-based contrast agent.
Step-by-step protocol:
- The patient is administered the contrast agent.
- Two minutes later, breast compression is performed.
- Dual-energy exposure is conducted in a single compression.
- Images are acquired in standard projections: craniocaudal (CC) and mediolateral oblique (MLO).
The system generates two types of images: low-energy images (equivalent to conventional 2D mammography) and recombined high-energy images, which clearly demonstrate areas of contrast uptake.
Advantages and clinical significance
CESM has high diagnostic value. Compared to standard mammography, the method significantly improves sensitivity and specificity in the detection of breast cancer.
- MRI alternative: In terms of sensitivity, the method is close to magnetic resonance imaging, and it surpasses MRI in specificity. At the same time, CESM is less expensive, more accessible, and better tolerated by patients.
- First-line diagnostics: Effective for palpable masses. It allows immediate assessment of tumor size and detection of occult multifocal lesions.
- Complex problem solving: Used for equivocal results of standard examinations and is considered a promising screening method for high-risk breast cancer patients with contraindications to MRI.
Limitations and drawbacks
Despite its high efficacy, the method has several limitations:
- Increased radiation dose: It is 1.2–1.8 times higher than in conventional mammography, although it remains within acceptable limits.
- Allergy risk: Associated with the use of iodine-containing agents.
- Background enhancement: Similar to MRI, physiological contrast enhancement of healthy tissue is possible. It depends on breast density, menopausal status, and ongoing hormone or radiation therapy.
Clinical example
Consider the case of a patient with dense parenchymal background and a palpable nodule.
On the low-energy image (equivalent to 2D mammography), the lesion is not visualized as it is obscured by dense breast tissue. However, on the recombined high-energy image, focal contrast uptake is clearly visible.
Conclusion: A high-grade solitary ductal carcinoma (high-grade ductal carcinoma) measuring 12 mm was detected, followed by wide local excision.
Briefly: answers to topical questions
What are the absolute and relative contraindications to intravenous contrast administration in spectral mammography?
The materials do not provide a specific list of absolute and relative contraindications for spectral mammography per se, but the method requires the administration of an iodine-based contrast agent, which has the following limitations:
- Renal impairment — not an absolute contraindication, but contrast administration should be avoided at an eGFR < 30 mL/min/1.73 m².
- History of allergies — adverse reactions to the iodine-based contrast are possible, ranging from mild to severe anaphylactic reactions.
- Thyrotoxicosis — elevated thyroid hormone levels requiring endocrinology consultation.
What are the exact sensitivity and specificity percentages of CESM in breast cancer diagnosis?
Exact percentages for the sensitivity and specificity of spectral mammography are not presented in the sources. It is only stated that for local breast cancer staging, the sensitivity of the method approaches that of magnetic resonance imaging, and its specificity is higher. Meanwhile, the sensitivity of MRI itself in detecting invasive breast cancer approaches 100%.
Class and exam questions
What is the main difference between CESM and conventional mammography?
CESM uses intravenous contrast and dual-energy imaging to visualize the tumor vascular network, whereas conventional mammography only assesses structural tissue density.
Can breast MRI be replaced by CESM?
Yes, for local breast cancer staging, the method is comparable to MRI in sensitivity, has higher specificity, and is used in patients for whom MRI is not suitable.
What can cause background contrast enhancement in healthy tissue?
It depends on the menopausal status, breast density, and the administration of hormone replacement therapy or radiation therapy.
What else to study on this topic
- The role of ultrasound in the diagnosis of breast masses
- Principles of selecting ultrasound transducer frequency
- Compression elastography
- Shear wave elastography (SWE)
Master the entire topic in the "Diagnostic Radiology" course
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