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


      • Four percent of contrast enhanced mammography examinations contained an enhancing finding seen only on subtraction images, ie, without low energy mammographic or sonographic correlate.
      • Twenty percent of enhancing findings seen only on subtraction images were downgraded to benign after undergoing correlative MR.
      • Twenty six percent 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 December 2015 to May 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 a statistically significant difference.


      Four percent (100/2464) of CEM examinations identified 108 enhancing findings seen only on subtraction images. Twenty of those CEM enhancing findings were directly managed as a 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 were seen only on subtraction images, these included: 20% (12/59) and downgraded to benign on MR 80% (47/59) with 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 are 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 tissue sampling or empiric surgical planning for suspicious findings.



      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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