BREAST RADIOLOGY / ORIGINAL PAPER
Advancing clinical staging in invasive breast carcinoma: the role of contrast-enhanced mammography
1
Department of Radiology, Greater Poland Cancer Centre, Poznan, Poland
2
Department of Electroradiology, Poznan University of Medical Sciences, Poznan, Poland
3
Greater Poland Cancer Registry, Greater Poland Cancer Centre, Poznan, Poland
4
Department of Medical Physics, Greater Poland Cancer Centre, Poznan, Poland
5
Greater Poland Cancer Centre, Poznan, Poland
6
Department of Gastrointestinal Surgical Oncology, Greater Poland Cancer Centre, Poznan, Poland
These authors had equal contribution to this work
Submission date: 2025-01-08
Acceptance date: 2025-02-23
Publication date: 2025-05-07
Corresponding author
Piotr Radomyski
Department of Radiology, Greater Poland Cancer Centre, 15 Garbary St., 61-866 Poznan, Poland
Department of Radiology, Greater Poland Cancer Centre, 15 Garbary St., 61-866 Poznan, Poland
Pol J Radiol, 2025; 90: 207-214
KEYWORDS
TOPICS
ABSTRACT
Purpose:
This study compares breast carcinoma (BC) clinical tumour staging by contrast-enhanced mammography (CEM), full-field digital mammography (FFDM), and ultrasound (US). Clinical staging is essential for multidisciplinary teams to develop optimal treatment plans and for cancer registries to generate accurate analyses of cancer epidemiology.
Material and methods:
Data on tumour size and the presence of multiplicity were extracted from radiology reports. Primary tumour staging (cT category) was established for each imaging modality. Enrolled cases (n = 78, adult females) had FFDM and US performed up to a month prior to CEM. Fisher’s exact test was used to examine the relationship between cT stage determination and diagnostic methods.
Results:
Tumour size was largest in CEM (median 47 mm), followed by FFDM (median 33 mm), and smallest in US (median 23 mm). There were statistically significant differences in the distribution of cT categories between the 3 imaging modalities, with cT2 and cT1 being most common in US (46% and 41%, respectively) and FFDM (53% and 19%, respectively). Staging by CEM followed a different pattern, with cT2 and cT3 being most common (both 38%). The multiplicity rate was equal for CEM and US (42%), with fewer cases in FFDM (13%).
Conclusions:
The tumour size measured by CEM is greater compared to measurements obtained through US and FFDM. Given the strong correlation between CEM and histopathology reported in the literature, CEM enhances the accuracy of local tumour staging in BC, thereby minimising the risk of understaging.
This study compares breast carcinoma (BC) clinical tumour staging by contrast-enhanced mammography (CEM), full-field digital mammography (FFDM), and ultrasound (US). Clinical staging is essential for multidisciplinary teams to develop optimal treatment plans and for cancer registries to generate accurate analyses of cancer epidemiology.
Material and methods:
Data on tumour size and the presence of multiplicity were extracted from radiology reports. Primary tumour staging (cT category) was established for each imaging modality. Enrolled cases (n = 78, adult females) had FFDM and US performed up to a month prior to CEM. Fisher’s exact test was used to examine the relationship between cT stage determination and diagnostic methods.
Results:
Tumour size was largest in CEM (median 47 mm), followed by FFDM (median 33 mm), and smallest in US (median 23 mm). There were statistically significant differences in the distribution of cT categories between the 3 imaging modalities, with cT2 and cT1 being most common in US (46% and 41%, respectively) and FFDM (53% and 19%, respectively). Staging by CEM followed a different pattern, with cT2 and cT3 being most common (both 38%). The multiplicity rate was equal for CEM and US (42%), with fewer cases in FFDM (13%).
Conclusions:
The tumour size measured by CEM is greater compared to measurements obtained through US and FFDM. Given the strong correlation between CEM and histopathology reported in the literature, CEM enhances the accuracy of local tumour staging in BC, thereby minimising the risk of understaging.
REFERENCES (41)
1.
Sensakovic WF, Carnahan MB, Czaplicki CD, Fahrenholtz S, Panda A, Zhou Y, et al. Contrast-enhanced mammography: How does it work? Radiographics 2021; 41: 829-839.
2.
Lalji UC, Jeukens CRLPN, Houben I, Nelemans PJ, Van Engen RE, Van Wylick E, et al. Evaluation of low-energy contrast-enhanced spectral mammography images by comparing them to full-field digital mammography using EUREF image quality criteria. Eur Radiol 2015; 25: 2813-2820.
3.
McDonald DM, Baluk P. Significance of blood vessel leakiness in cancer. Cancer Res 2002; 62: 5381-5385.
4.
Niu J, Ma J, Guan X, Zhao X, Li P, Zhang M. Correlation between Doppler ultrasound blood flow parameters and angiogenesis and proliferation activity in breast cancer. Med Sci Monit 2019; 25: 7035-7041.
5.
James JR, Pavlicek W, Hanson JA, Boltz TF, Patel BK. Breast radiation dose with CESM compared with 2D FFDM and 3D tomosynthesis mammography. Am J Roentgenol 2017; 208: 362-372.
6.
Luczyńska E, Heinze S, Adamczyk A, Rys J, Mitus JW, Hendrick E. Comparison of the mammography, contrast-enhanced spectral mammography and ultrasonography in a group of 116 patients. Anticancer Res 2016; 36: 4359-4366.
7.
Lobbes MBI, Lalji U, Houwers J, Nijssen EC, Nelemans PJ, van Roozendaal L, et al. Contrast-enhanced spectral mammography in patients referred from the breast cancer screening programme. Eur Radiol 2014; 24: 1668-1676.
8.
Travieso-Aja MDM, Maldonado-Saluzzi D, Naranjo-Santana P, Fernández-Ruiz C, Severino-Rondón W, Rodríguez Rodríguez M, et al. Diagnostic performance of contrast-enhanced dual-energy spectral mammography (CESM): a retrospective study involving 644 breast lesions. Radiol Med (Torino) 2019; 124: 1006-1017.
9.
Helal M, Abu Samra MF, Ibraheem MA, Salama A, Hassan EE, Hassan NE-H. Accuracy of CESM versus conventional mammography and ultrasound in evaluation of BI-RADS 3 and 4 breast lesions with pathological correlation. Egypt J Radiol Nucl Med 2017; 48: 741-750.
10.
Mori M, Akashi-Tanaka S, Suzuki S, Daniels MI, Watanabe C, Hirose M, et al. Diagnostic accuracy of contrast-enhanced spectral mammography in comparison to conventional full-field digital mammography in a population of women with dense breasts. Breast Cancer 2017; 24: 104-110.
11.
Cheung YC, Lin YC, Wan YL, Yeow KM, Huang PC, Lo YF, et al. Diagnostic performance of dual-energy contrast-enhanced subtracted mammography in dense breasts compared to mammography alone: interobserver blind-reading analysis. Eur Radiol 2014; 24: 2394-2403.
12.
Grażyńska A, Niewiadomska A, Owczarek AJ, Winder M, Hołda J, Zwolińska O, et al. Comparison of the effectiveness of contrast-enhanced mammography in detecting malignant lesions in patients with extremely dense breasts compared to the all-densities population. Pol J Radiol 2024; 89: e240-e248. DOI: https://doi.org/10.5114/pjr/18....
13.
Cozzi A, Magni V, Zanardo M, Schiaffino S, Sardanelli F. Contrast-enhanced mammography: a systematic review and meta-analysis of diagnostic performance. Radiology 2022; 302: 568-581.
14.
Daniaux M, Gruber L, De Zordo T, Geiger-Gritsch S, Amort B, Santner W, et al. Preoperative staging by multimodal imaging in newly diagnosed breast cancer: diagnostic performance of contrast-.
15.
enhanced spectral mammography compared to conventional mammography, ultrasound, and MRI. Eur J Radiol 2023; 163: 110838. DOI: 10.1016/j.ejrad.2023.110838.
16.
Li L, Roth R, Germaine P, Ren S, Lee M, Hunter K, et al. Contrast-enhanced spectral mammography (CESM) versus breast magnetic resonance imaging (MRI): a retrospective comparison in 66 breast lesions. Diagn Interv Imaging 2017; 98: 113-123.
17.
Łuczyńska E, Heinze-Paluchowska S, Hendrick E, Dyczek S, Ryś J, Herman K, et al. Comparison between breast MRI and contrast-enhanced spectral mammography. Med Sci Monit Int Med J Exp Clin Res 2015; 21: 1358-1367.
18.
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; 142: 109883. DOI: 10.1016/j.ejrad.2021.109883.
19.
Steinhof-Radwańska K, Lorek A, Holecki M, Barczyk-Gutkowska A, Grażyńska A, Szczudło-Chraścina J, et al. Comparison of the efficiency of mammography, contrast-enhanced spectral mammography and magnetic resonance imaging in female patients with multifocal and multicentral breast cancer 2021. Curr Oncol 2021; 28: 4016-4030.
20.
Helal MH, Mansour SM, Zaglol M, Salaleldin LA, Nada OM, Hag-gag MA. Staging of breast cancer and the advanced applications of digital mammogram: what the physician needs to know? Br J Radiol 2017; 90: 20160717. DOI: 10.1259/bjr.20160717.
21.
Taylor DB, Burrows S, Saunders CM, Parizel PM, Ives A. Contrast-enhanced mammography (CEM) versus MRI for breast cancer staging: detection of additional malignant lesions not seen on conventional imaging. Eur Radiol Exp 2023; 7: 8. DOI: 10.1186/s41747-022-00318-5.
22.
Hafez MAF, Zeinhom A, Hamed DAA, Ghaly GRM, Tadros SFK. Contrast-enhanced mammography versus breast MRI in the assessment of multifocal and multicentric breast cancer: a retrospective study. Acta Radiol 2023; 64: 2868-2880.
23.
Fallenberg EM, Dromain C, Diekmann F, Engelken F, Krohn M, Singh JM, et al. Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size. Eur Radiol 2014; 24: 256-264.
24.
Dromain C, Thibault F, Muller S, Rimareix F, Delaloge S, Tardivon A, et al. Dual-energy contrast-enhanced digital mammography: initial clinical results. Eur Radiol 2011; 21: 565-574.
25.
Patel BK, Garza SA, Eversman S, Lopez-Alvarez Y, Kosiorek H, Pockaj BA. Assessing tumor extent on contrast-enhanced spectral mammography versus full-field digital mammography and ultrasound. Clin Imaging 2017; 46: 78-84.
26.
Blum KS, Rubbert C, Mathys B, Antoch G, Mohrmann S, Obenauer S. Use of contrast-enhanced spectral mammography for intramammary cancer staging. Acad Radiol 2014; 21: 1363-1369.
27.
Lu Z, Hao C, Pan Y, Mao N, Wang X, Yin X. Contrast-enhanced spectral mammography versus ultrasonography: diagnostic performance in symptomatic patients with dense breasts. Korean J Radiol 2020; 21: 442-449.
28.
Helal MH, Mansour SM, Salaleldin LA, Alkalaawy BM, Salem DS, Mokhtar NM. The impact of contrast-enhanced spectral mammogram (CESM) and three-dimensional breast ultrasound (3DUS) on the characterization of the disease extend in cancer patients. Br J Radiol 2018; 91: 20170977. DOI: 10.1259/bjr.20170977.
29.
O’Sullivan B, Brierley J, Byrd D, Bosman F, Kehoe S, Kossary C, et al. The TNM classification of malignant tumours-towards common understanding and reasonable expectations. Lancet Oncol 2017; 18: 849-851.
30.
McDonald ES, Clark AS, Tchou J, Zhang P, Freedman GM. Clinical diagnosis and management of breast cancer. J Nucl Med 2016; 57: 9S-16S. DOI: 10.2967/jnumed.115.157834.
31.
Dorn PL, Al-Hallaq HA, Haq F, Goldberg M, Abe H, Hasan Y, et al.A prospective study of the utility of magnetic resonance imaging in determining candidacy for partial breast irradiation. Int J Radiat Oncol 2013; 85: 615-622.
32.
Mazor AM, Mateo AM, Demora L, Sigurdson ER, Handorf E, Daly JM, et al. Breast conservation versus mastectomy in patients with T3 breast cancers (> 5 cm): an analysis of 37,268 patients from the National Cancer Database. Breast Cancer Res Treat 2019; 173: 301-311.
33.
Bleicher RJ, Ruth K, Sigurdson ER, Daly JM, Boraas M, Anderson PR, et al. Breast conservation versus mastectomy for patients with T3 primary tumors (> 5 cm): a review of 5685 medicare patients. Cancer 2016; 122: 42-49.
34.
Radomyski P, Trojanowski M, Michalek IM, Kycler W. The impact of the COVID-19 pandemic on clinical staging, pathological staging and surgical management of breast cancer patients. Rep Pract Oncol Radiother 2024; 29: 122-130.
35.
Radomyski P, Trojanowski M, Fundowicz M, Litwiniuk M, Kycler W. Clinical and epidemiological characteristics of Ukrainian breast cancer patients in a regional cancer center in Poland after the start of the war in Ukraine. Rep Pract Oncol Radiother 2025; 29: 710-717.
36.
Lee CH, Phillips CJ, Sung JS. ACR BI-RADS®. In: ACR BI-RADS® Contrast Enhanced Mammography (CEM). A supplement to ACR BI-RADS® Mammography 2013 Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2022.
37.
Brierley JD, Gospodarowicz MK, Wittekind C (Eds.). TNM Classification of Malignant Tumours, 8th ed. Chichester, UK: John Wiley and Sons; 2017.
38.
Elm EV, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335: 806-808.
39.
Gruber IV, Rueckert M, Kagan KO, Staebler A, Siegmann KC, Hartkopf A, et al. Measurement of tumour size with mammography, sonography and magnetic resonance imaging as compared to histological tumour size in primary breast cancer. BMC Cancer 2013; 13: 328. DOI: 10.1186/1471-2407-13-328.
40.
Stachs A, Pandjaitan A, Martin A, Stubert J, Hartmann S, Gerber B, et al. Accuracy of tumor sizing in breast cancer: a comparison of strain elastography, 3-D ultrasound and conventional B-mode ultrasound with and without compound imaging. Ultrasound Med Biol 2016; 42: 2758-2765.
41.
Hieken TJ, Harrison J, Herreros J, Velasco JM. Correlating sonography, mammography, and pathology in the assessment of breast cancer size. Am J Surg 2001; 182: 351-354.
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