Contrast Enhanced Mammography in Routine Clinical Practice: Frequency and Malignancy Rates of Enhancing Otherwise Occult Findings


      • 4% of contrast enhanced mammography examinations contained an enhancing finding seen only on subtraction images, i.e.: without low energy mammographic or sonographic correlate.
      • 20% of enhancing findings seen only on subtraction images were downgraded to benign after undergoing correlative MR.
      • 26% of enhancing findings seen only on subtraction images that underwent biopsy were malignant on pathology.
      • Image-guided tissue biopsy should be considered for enhancing findings seen only on subtraction images, using either CEM or MR guidance.



      In routine clinical practice, contrast enhanced mammography (CEM) examinations identify enhancing findings seen only on subtraction images that have no low-energy mammographic or sonographic correlate. The purpose of this study is to report the frequency and malignancy rates of enhancing findings seen only on subtraction images in a tertiary care breast imaging practice.

      Materials and methods

      Consecutive review of CEM exams from 12/2015- 05/2020. Chi square tests were used to determine associations between cancer diagnosis and clinical characteristics of enhancing findings seen only on subtraction images, p < .05 indicating statistically significant difference.


      4% (100/2464) CEM examinations identified 108 enhancing findings seen only on subtraction images.  Twenty of those CEM enhancing findings were directly managed as multifocal disease. Of those further evaluated with MR, 23% (19/78) with associated MR correlates were treated surgically as presumed multicentric or multifocal disease following multidisciplinary review. The remaining 76% (59/78) of enhancing findings seen only on subtraction images included: 20% (12/59) were downgraded to benign on MR, 80% (47/59) had suspicious findings which underwent MR vacuum assisted breast biopsy yielding: 26% (12/47) malignancy, 9% (4/47) high risk, and 66% (31/47) benign diagnoses.


      Enhancing findings seen on subtraction only CEM images is seen in 4% of cases in clinical practice. MR correlation can help characterize CEM findings to: 1) avoid unnecessary biopsy for benign findings and 2) guide for tissue sampling or empiric surgical planning for suspicious findings.
      Microabstract: The purpose of this study is to report the frequency and malignancy rates of enhancing findings seen only on subtraction images on contrast enhanced mammography in a tertiary care breast practice. Consecutive review of CEM exams from 12/2015- 05/2020 identified 4% of CEM examinations containing an enhancing finding seen only on subtraction images, i.e.: without low energy mammographic or sonographic correlate with PPV3 of 26%.



      CEM (Contrast Enhanced Mammography), MRI (Magnetic Resonance Imaging), PPV (Positive Predictive Value), MR-VABB (MR-guided vacuum-assisted breast biopsy), NME (non-mass enhancement), CAD (computer assisted device), BI-RADS (Breast Imaging Radiology and Data Systems)
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