Hello, my name is Almir Bittencourt and I am a breast radiologist in Brazil. Because we do not have much time, I will focus on one specific indication which is more common in my clinical practice, that is preoperative staging and treatment planning. I will present five quick cases that I hope will help you understand the role of contrast-enhanced breast imaging for this specific test. The first case is a 45-year-old female patient that came to our institution for a second opinion after having a BioRxiv on a prior mammography due to focal asymmetry with calcifications in the right breast. In her mammur, this was the focal asymmetry with calcifications. We can also observe that there were other obscured masses in both breasts. Magnification view characterizes some of those calcifications as intrasystems, as we can see here, but tonal synthesis shows also a small speculated mass in the same breast. On ultrasound, confirmed that the focal asymmetry corresponded to a multiloculated cyst, that there were many other cysts like this in both breasts. And the speculated mass corresponded to a hypoechoic irregular mass, which was biopsied and confirmed as an invasive ductal carcinoma. The patient also presented other probable masses in both breasts. And because it is difficult to evaluate the breasts on both mammals and ultrasounds due to the multiple cysts and masses, breast MRI was performed. This is the subtracted 3D reconstruction after contract administration showing the main tumor in the right breast and other enhancing masses in the left breast. And this is the 3D reconstruction from the two weighted images, just for you to have an idea of how many cysts this patient had. Focusing on the right breast, we can observe here the irregular mass, associated with a small satellite lesion, and both lesions had a low sinal intensity on the two weighted images, and also restricted diffusion with ADC values of 0.8 and 0.9. On the left breast, there were three irregular masses, as we can observe here, with heterogeneous and persistent enhancements. Two of them were already described in the prior ultrasound, and the other one was characterized on second look ultrasound, as an hypoechoic mass near to the nipple. The interesting thing is that these masses had a very high sinal intensity on the two weighted images, similar to cysts like we can see here, and also very high ADC values on diffusion weighted images. Although fibroadenomas can have high sinal intensity on the two weighted images, it is usually not so high, and these signs are typically observed in miscellaneous carcinoma of the breast. So those lesions were submitted to biopsy and posterior bilateral mastectomy, which confirmed a no special type invasive breast carcinoma, subtype luminal B, on the right breast, and on the left breast, a multifocal invasive mucinose carcinoma, subtype luminal A. So this case shows that multiparametric breast MR can provide information about disease extents, and also about tumor biology. These are some pictures from some beaches in Brazil. I hope you can come in the future to check that in person also. The other cases are less complex. This one is from a 50-year-old woman who presented with palpable lump in the left breast, which was confirmed as a no special type invasive carcinoma. So conventional mammography showed a round mass in the inner quadrant of the left breast, and enlarged axillary lymph nodes. In contrast, enhanced mammal also showed two additional enhanced lesions, one in the upper outer quadrant and the other in the utero-allelar region. Both lesions were also identified on breast MR and confirmed as breast centric disease. The third case is from a 68-year-old female patient, also who had palpable lump in the left breast. Mammography showed an heterogeneous dense breast, with an architectural distortion in the topography of the palpable lump. But contrasting enhanced mammals showed very characterized speculated mass in the left breast, and also showed an area of no mass enhancement in the right breast. Both lesions were confirmed on breast MR, and after biopsy we confirmed a synchronous invasive ductal carcinoma in the left breast and invasive ovular carcinoma in the right breast. So the teaching point here is that contrast enhanced mammography can also be used to find additional suspicious lesions in breast cancer patients. In Brazil we still have very few institutions that perform contrast enhanced mammography, but I think with a larger availability this can be a very useful tool in our clinical practice, especially due to the lower cost when compared to MR. And at last I want to show two quick cases to illustrate an alternative for local regional staging in breast cancer patients, which is conventional contrast enhanced boot detector CT with dedicated protocol for breast evaluation performed in prone position, similar to MR. The rationale here is the same as contrast enhanced mammal, using iodinated contrast to help differentiate malignant tumors from the normal tissue. We have been using this protocol in our institution for breast cancer patients who already performed chest CT for distant staging, so no additional radiation or contrast is required. We just performed the exam in prone position using this device to improve the evaluation of the breast and allow better comparison with MR. The first case is a 42-year-old female patient with palpable lump in the left breast, spanning 5 cm on physical examination. Mammography showed only dense breast and ultrasound showed 1.8 cm irregular mass, which was confirmed as no special type invasive carcinoma, subtype luminal B. The patient came to our institution to perform the treatment and the oncologist requested a chest and abdominal CT for staging. So evaluation of the breast on chest CT in prone position showed additional lesions near the main tumor, spanning 5.5 cm, which corresponded to the physical examination and also showed an additional lesion in the junction of the outer quadrant, suggesting mutucentric disease, which was confirmed later on MR and also after surgical resection. And the last case is a 67-year-old female patient, who showed a 2.2 cm irregular mass on both mammo and ultrasound, which was confirmed as no special type invasive breast carcinoma, subtype HER2. On multi-detector CT, we observed a mass in the lower outer quadrant of the right breast associated with a large area of non-mass enhancement with segmental distribution spanning 7 cm, suggesting extensive interductal components, which was also confirmed on MRI and after surgical resection. Of course, these are initial results, but we believe prone multi-detector CT can be an alternative for breast cancer staging in patients who already performed chest CT for distance staging, especially when MR and contrast-enhanced mammo are not available. To finish, I would like to conclude that contrast-enhanced breast imaging is an important tool to help define disease extents and may impact on treatment planning. MRI, of course, provides more information based not only on contrast enhancement, but also T2 and diffusion. But contrast-enhanced mammo and even multi-detector CT can be used as alternatives on selected cases depending on what method you have access to. Thank you very much for your attention. Hello everyone. I'm Masako Kataoka from Kyoto University, Kyoto, Japan. It's my great honor to present case-based review. I picked up three interesting cases with a focus on breast MRI. Case 1. A female in her early 40s came to the clinic for palpable mass in her right breast. Outer sonography demonstrates right and left masses. Mammography revealed bilateral myoclical calcifications and distortion in the left breast. Outer sonography showed over-low aqueous mass with circumscribed margin in the right breast, irregular-shaped low aqueous mass with irregular margin in the left breast. On MRI, right-sided mass was identified or both circumscribed with slow persistent enhancement. The target region in the left breast is difficult to find due to marked background parenchymal enhancement, VPE. Here in this case, we scanned this patient using ultrafast dynamic contrast enhanced MRI. On ultrafast DC MRI, very early phase, soon after the injection on contrast agent is scanned at every 4 seconds. Early enhancement region is visible before VPE appears. Look at the actual images. Now the region starts to enhance. On the last phase of ultrafast DC MRI, the left cancer stands out from the background. The patient underwent surgery of the left breast. Pathological diagnosis was invasive carcinoma, NSD, luminal type. Ultrafast DC MRI was proposed by Mang et al. in 2014. In this paper, breast cancer of ultrafast images are described as tumor stands out, like a light bulb. This technique can pick up early and fast enhanced region. Ultrafast DC MRI can be used to avoid the effect of VPE, which appears a bit late. In another case here, left breast mass is shown on both ultrafast and early DC images, while visibility is better on ultrafast DC MRI. In summary, ultrafast DC MRI can be used to improve visibility for rapid enhancing vascular deletions, avoiding the effect of VPE. Now move on to case 2. Female in her 40s noticed right breast mass, which was rapidly increasing in size. MRI showed two enhancing masses here and here. Persistent kinetics with high signal intensity on DWI and very low ADC values. Two enhancing masses with high signal intensity on diffusion-weighted image even on high B-value image and very low ADC value of 0.5. Biopsy was performed, and pathological diagnosis was diffused large B-cell lymphoma, where it is positive for CD20, CG79A. Primary breast lymphoma in a broad sense may be defined as dominant mass or symptom in the breast without known lymphoma. It is rare, typically present as painless unilateral mass. Half of them are diffused large B-cell lymphoma. Image findings of breast lymphoma are summarized below. They are similar to invasive carcinoma. Possible key findings to indicate lymphoma is lower ADC value than most of the invasive carcinoma, like in this case and other cases. This probably reflects high similarity on pathology. In summary, MRI finding of breast lymphoma is similar to invasive carcinoma. Very low ADC value may help in suggesting the diagnosis of lymphoma. Now move on to case 3. Female in her 50s deferred to our hospital due to abnormal finding of right breast at opportunistic screening. She has no symptom. On mammogram, small mass was visible on lower part of abdomen. On CC, small mass was found at the inner part of right breast. Autoethnography showed 5 mm low echoic mass at the inner area of the right breast. She underwent dedicated breast PET as a part of screening. Autoethnography showed 5 mm low echoic mass at the inner area of the right breast. She underwent dedicated breast PET as a part of screening, which showed two regions. Forecast and mass uptake at right upper inner area. Mass was oval shape, homogeneous internal pattern, intense uptake, 20 mm. Forecast showed intense uptake, 5 mm in size. Go back to mammography. Focal asymmetric density was found here. Autoethnography showed small low echoic non-mass region on upper inner area of the right breast, corresponding to the mass on DB PET and mammography. On MRI of the right breast at axial image, 20 mm irregular-shaped mass is seen at right upper inner area. Speculative margin, fast plateau kinetics, high signal intensity on tissue-weighted image and diffusion-weighted image. In addition, 5 mm focal non-mass enhancement was seen at right inner area. We tried to make fusion image of dedicated breast PET and contrast-enhanced MRI. Sizes are almost equal between the two modalities. While detailed speculative structure can be seen only on MRI. C-annulment surgery. Pathological diagnosis were invasive carcinoma NST, luminal HER2 type, for both regions. Dedicated breast PET demonstrated high spatial resolution. High sensitivity improved detection for small cancers compared to whole-body PET. Morphology observation is similar to that on MRI. Like this case, limb uptake and limb enhancement. Research is ongoing for presurgical evaluation. Neoadjuvant treatment prediction and screening. For standardization, efforts are made for making VIXCON, like mass, non-mass, focus, based on bilas MRI. Now we come to notice that metabolic morphology on PET is not always equal to MRI morphology. DB PET may be sensitive to the local metabolic activity, while MRI can demonstrate detailed morphology including shape, density, and size. While MRI can demonstrate detailed morphology including shape, margin, and tiny ductile lesions. They look at cancer in a different viewpoint. What does this mean? This is a hot topic of research. In summary, DB PET may help in identifying small cancers. Morphology on DB PET may not agree with morphology on MRI, and their different roles are under investigation. Finally, I appreciate support from my colleagues, breast surgeons, pathologists, and vendors. Thank you for listening. Hi, good morning. I'm Jonathan James. I'm a consultant radiologist from the UK. We do quite a lot of contrast-enhanced mammography as part of our symptomatic practice. So I'm going to present a little bit of information about how we do contrast-enhanced mammography. And also show some cases where we found it a useful addition to our diagnostic pathway. These are a list of the indications for contrast-enhanced mammography from the literature. And we've already heard from Dr. Bittencourt earlier on about using it for preoperative staging of primary breast cancer. And we are, particularly like in Holland, they're doing an awful lot of contrast-enhanced mammography. And we are, particularly like in Holland, they're doing an awful lot of contrast-enhanced mammography. They're doing an awful lot of using CSM as part of the screening assessment process. There's increasing interest in screening high-risk women in the UK. We're doing that as part of a study called BRAID. We're also using it to monitor the response to neuroadjuvant chemotherapy, particularly when patients perhaps aren't suitable to have breast MRI. And the final group there is what I use it for most often in my practice, which is the evaluation of symptomatic women. So I'm going to focus on using CSM in that context. So if you attend my clinic in the UK, and actually it's the same for most breast clinics in the UK, they are one-stop clinics where the patients are examined first by a surgeon, or actually increasingly a nurse practitioner. And then the imaging is all carried out at the same clinic episode. So they're examined first, and then they come through for the imaging at the same clinic visit. So we've had contrast-enhanced mammography in our unit since 2013, and we developed a protocol where anybody who comes with a clinically suspicious mass, we go straight to a contrast-enhanced mammogram as the first-line mammographic technique. We're not doing FFDM or TOMO. We go straight to a contrast-enhanced mammogram for anybody with a clinically suspicious mass. We tend not to do the over-70s, as I've said there, because actually we don't always have renal function available to us at the time the patient comes to the clinic. And actually sometimes the over-70s, it sometimes is beneficial to have renal function. But actually in reality, a lot of the over-70s have a fattier background pattern anyway, and so the benefits from having contrast-enhanced mammography are somewhat reduced. The other situation in our one-stop clinic where we'll use contrast-enhanced mammography is in younger women who we wouldn't routinely do a mammogram on, but when we actually do that ultrasound as the first-line imaging test, we find a suspicious abnormality on ultrasound, and then before we go on and do the biopsy, we do a contrast-enhanced mammogram at that point. So I'm just gonna start off by showing you a couple of cases just to illustrate those uses of contrast-enhanced mammography in our one-stop clinic. So the first case is a 63-year-old. She's come to our clinic. She's examined by the surgeon, and there's a clinically suspicious mass in her left breast. So we're gonna go straight to a contrast-enhanced mammogram. We're not going to do a normal 2D FFDM mammogram, first of all. Just to remind you about the technique, it's a bit of a sort of two-for-the-price-of-one technique is contrast-enhanced mammography. We inject the standard low-osmolality alternating contrast agent. You wait two minutes, and then in the same compression, effectively two images are acquired, a low-energy image, which looks like a standard mammogram, looks like a 2D mammogram, and we know from literature that it really has the same characteristics as a 2D mammogram. So this is this lady's low-energy components for a CSM study, and as I say, she's got a clinically suspicious mass in the left breast, and you can probably just appreciate it poking on there at the back of the left oblique projection. Again, the low-energy CC images which she's had, you can see a very obvious suspicious lesion lying there medially in the breast. You're probably thinking to yourself now, well, why on earth do we need contrast-enhanced mammography here? That's extremely obvious what's going on in this breast. It's not even particularly dense either. Why do we need contrast mammogram? Well, let's have a quick look now at the recombined images which are part of the CSM study. So if you look at the recombined image, yes, we're seeing that enhancing lesion at the back there, but hopefully you might note there might be something going on nearer the nipple, and I challenge you to pick that up on the low-energy component of the CSM study. And again, if we look at the CC view, yes, there's a very obvious cancer lying medially in the breast, but we've got another lesion near the nipple. So the great strength now of using CSM in the one-stop symptomatic clinic is we can actually now go to ultrasound at the same clinic visit, and we can go and find both those mass lesions. So on ultrasound, when we ultrasound the medial aspect of the breast, the top image there, we can find that suspicious-looking mass there, but also when we look behind the nipple in the retroareolar area where we've got that additional enhancing lesion, we can see a second area there. So we can biopsy those at that first clinic visit, and then when the patient comes back for the results to see the surgeon, both of those are malignant. So we've got very accurate staging information at that first clinic visit. We know there's no additional lesions there, and the patient in this case was able to have breast-conserving surgery because we're able to mark both those areas and do wide excision of both those areas. So really very good sort of staging information. We're being extremely confident about what's going on for this patient. The second scenario where we would do CSM in the one-stop clinic is in some of our younger patients who wouldn't routinely get a mammogram as their first-line investigation. So this is a 35-year-old who's come this time with a more indeterminate mass in the left breast. So again, she's been examined by the surgeon. Yes, there's a mass there, but it's indeterminate. So she goes for an ultrasound first of all, like I'm sure many of you, we don't tend to do mammography routinely in the under 40s. So this is what the mass looks like, an ultrasound. It's a little bit sort of shaggy around the edges there, so a little bit indeterminate there. So we were a little bit concerned about those ultrasound appearances. So in this scenario, this is the time where we would then go and do a contrast-enhanced mammogram before we do the biopsy. So she went on to have a contrast-enhanced mammogram, again, at that same, that first clinic visit. And this time on the low-energy image, we've got a much denser background pattern. She's only 35, so a denser background pattern. So again, really quite difficult to see what's where this lesion actually is. Again, on the CC view, again, a very dense background pattern there. And if we look at the recombined image of the CSM study, so that iodine-only image, we're seeing that cancer extremely well there. Again, we can be very confident it's a sultry lesion. And actually, these are the sort of cases that often will go on to have an MRI, but we've got that very good staging information at that first clinic visit. This was our slightly older CSM machine, and it actually gives you a little bit of artifact, which is that sort of slight sort of rim artifact here. It's due to a scatter effect. And actually, on the latest generation of the software that we have, those rim artifacts are actually significantly reduced. So again, if we just look at the other study, the rim artifact is there, but we're clearly seeing that sultry mass there. So again, at that first clinic visit, I can now tell the patient that, yes, I'm very confident we've just got a sultry mass there. We can go on and biopsy that mass. It's malignant, invasive, and this lady can go on to have a wide excision when she sees the surgeon. And again, we don't need to do an MRI study because we've got very good staging information at that first clinic visit. So those are the two scenarios where we tend to use contrast-enhanced mammography in our own symptomatic practice in the UK. Okay, I'm gonna present three cases now where we're using CSM, the slightly more challenging management. So first lady who's come to the clinic that you're gonna help me with is a 61-year-old patient with a clinically suspicious mass in her right breast. So clinically suspicious, we're gonna go and do a contrast-enhanced mammogram for this patient. And there's a low-energy image, and we've got a relatively well-defined mass in that breast. Again, on the CC, relatively well-defined. Yeah, looking at that, it looks actually more on the benign side. So let's have a quick look at the CSM. It could be a cyst even. On the recombined image for the oblique projection, it's not enhancing terribly well there. There is some, it doesn't absolutely look like a cyst, which would tend to be a sort of, you'd have a sort of a void there or even a sort of an eclipse sign. On the CC view, yes, there is a little bit more enhancements there, but it's rather patchy in that lesion. But we know it's a solitary lesion there. When we look at it with ultrasounds, it's a part solid, part cystic lesion. So there's cystic elements to it, but there's also a solid component as well. So we drained some of the fluid off from it, and we did a core biopsy through the residue of that lesion at that, in that clinic visit. So she had a 14-gauge core biopsy, and we placed a marker clip as well. I'm sure like you, all our biopsies that we take in the breast clinic, they come to a multidisciplinary meeting or tumor board meeting to discuss management, look for radiological pathological concordance. So we come to the tumor board meeting. So the pathologist puts the images up for us, and we've got sort of this frond-like structure here. It's lined by quite sort of regular cells here. And the pathologist tells us that this is a papilloma with no atypia. What we call in Europe and the UK a B3 lesion, a lesion of uncertain malignant potential. So this is a papilloma with no atypia at the tumor board. So the question I'm going to ask you at the tumor board is the ultrasound-guided core biopsy shows parts of a papillary lesion with no atypia. What is your recommendation at the tumor board? I think, so let's go through some of those answers. First, yes, I don't think it's really appropriate to do nothing. I mean, the upgrade rate for papilloma with no atypia to malignancy, round about seven to 8%, so fairly small, but there is a chance sometimes that these lesions do harbor malignancies. I think we do have to do something else for them. Again, in terms of just surveillance, there is this chance of upgrade to malignancy, so I don't think just doing nothing necessarily is an option. I don't think we need to do an MRI. We've got very good staging information from that CSM, and anyway, it was a fairly fatty breast as well. So yes, I do think we need to take some more tissue from there. If you're asking this question in my unit about seven or eight years ago, I'd probably go with sort of the 45% of you for the open surgical biopsy and actually remove the lesion, but actually increasingly now in UK practice and certainly in my own unit, we'd actually opt for a vacuum-assisted excision. So we'd use our vacuum device, we'd put the needle into the area, and we'd be aiming to take around sort of four grams of tissue to effectively take the amount of tissue that a surgeon would take at the time of a diagnostic surgical excision. So that's indeed what we did. So we got our vacuum device. Take off some noise, sorry. And we tripped away because it's quite satisfying actually doing papillomas because all the fluid disappeared and we tripped away at the solid bit. So we aimed to take around four grams of tissue. So we removed the lesion very quickly. We sampled the area around it. And final pathology, yes, there's just a papilloma with no atypia here. There was no additional abnormality there. We actually don't need to follow this lady up, particularly with anything additional because actually there's very little risk of future malignancy in a papilloma with no atypia. Okay, our next lady who's come to our symptomatic clinic is a 61-year-old with a clinically suspicious mass in the retroareolar area of the right breast. So again, clinically suspicious. We're gonna go straight to a contrast-enhanced mammogram for this patient. So here's our low-energy image. It's immediate background density in this case, but even on the low-energy image, we can see that rather suspicious lesion in the retroareolar area. Again, on the CC view of the CSM study, the low-energy image, again, we're seeing that suspicious mass there. We've also got the recombined image to look at as part of the CSM study. And again, we've got that abnormal enhancement associated with the tumor behind the nipple. But I'm just starting to wonder, is there something else appearing just in the top part of that breast on, of the right breast on the recombined image there? So is there something else going on there? So let's have a look at the CC view. And again, the cancer there behind the nipple is very obvious, or very suspicious lesion behind the nipple, but I think we've got another lesion going on in this area here. So when I go into the ultrasound for this patient, I'm going to have a look where she's got a symptomatic mass. I'm also gonna see if I can find that additional lesion in the upper half of the breast. So there's the mass behind the nipple. Yes, looking very suspicious. And certainly, we're going to biopsy that, which is what we did. 14-gauge core biopsy of that lesion. And I had a look in the upper outer quadrant of the breast, and there was a little nodule up in that area, as I could see. So it was eight millimeter hypokote nodule in the upper outer quadrant. So I do a 14-gauge core biopsy. Really important to put a marker clip into some of these tiny things, because they have a nasty habit of becoming something that you need to find again, and then you can't find them. So put a marker clip in. And actually, the marker clip's quite useful as well, because we can just make absolutely sure that what we've biopsied is actually the lesion that I've seen on the CSM. So just to try and convince you of that, there's the, I did a check image after I put the marker in, but hopefully I can convince you that it is the same lesion that we're seeing on the CSM on that recombined image. Okay, so we're coming to the tumor board. We've done both the biopsies of those. We're coming to the tumor board again. So get ready to help me out with the management. So in the right breast, we've got this very abnormal-looking cells in the biopsy from behind the nipple. We've got really big nuclei here. There's some mitotic figures. There's no attempt here to form any sort of breast architecture. So this is a high-grade tumor. So this is an invasive adenocarcinoma of mammary type, provisional core grade three. So high-grade cancer behind the nipple. So what about the biopsy from the upper outer quadrant to the right breast? Most of it actually is a cyst. So we've got a big cystic space here with nice regular cells around it. So there's sort of very normal cells lining that cyst, but just to the left of it there is an abnormal proliferation. So we've got some rather large cells there. So there's some slightly big-looking cells with big nuclei here. So the pathologist says, well, this is a lesion of uncertain polygamy potential. It's predominantly fibrocystic change, what we've seen there, but there is a typical lobular neoplasia. So lobular hyperplasia, which we classify as B3 with atypia. Okay, so we've got this area of atypical lobular neoplasia away from the primary tumor site. What are we gonna suggest at the MDT? Certainly like most of you, I do think, we certainly can't just ignore this and assume it's benign, but equally, we can't assume it's malignant and go and do a mastectomy. So we do have to investigate a little bit further. Again, I remind you this, we've had a CSM study here. So I really don't think we need to do an MRI here because we've got very much equivalent information from the CSM as we would get from an MRI. We know there's a cancer there. We know there's a very tiny little thing in the upper half of the breast and nothing else. So I don't think MRI is gonna add anything else to this case. So I think like you, I think we need to get tissue from that area to know what's going on. Now, this time with lobular hyperplasia, the upgrade rate to malignancy is a bit higher than that papilloma with ATP, around about 27, 28% in the literature for lobular neoplasia. So yes, I think we could do an open surgical biopsy at the time we treat that breast cancer behind the nipple. The problem is that she hadn't got very big breasts, so we could actually potentially compromise cosmesis by doing a second sort of biopsy of that small area. The other thing as well that could happen if we do a open surgical biopsy at the time of the wide excision, should it turn out to be malignant, then the patient would need to go back and potentially have a second operation. So again, we elected actually to do a vacuum-assisted excision before we went on to treat this patient. So we went back to that site and we excised, we were gonna take some more tissue, say around about four grams we'd be aiming for, which if you're using a sort of seven-gauge needle, that's around about 12 cores with a seven-gauge needle. This time, because it was such a tiny little thing we couldn't see it very well again on ultrasound after we'd done the biopsy, so we elected to do this biopsy under X-ray guidance and target the marker clip that I placed at the time of the original biopsy. So we stuck the vacuum needle in there. We use a lateral arm approach actually often with our biopsies, so we're seeing the needle there overlying the clip. And we've actually taken our biopsy there, we've removed the clip, and we've got that sort of little cavity there that's left behind. You can see the tumour there as well, just to the right of the lesion. So the tumour bore, the final abnormality there from the vacuum-assisted excision was just lobular neoplasia, and the biopsy sites, that was all that was there. So we can confidently now go on and treat the cancer that's there in that right breast. And so this patient was suitable for breast conserving surgery, which was the treatment she accepted, and we just had a 24-millimeter high-grade ductal and lobular carcinoma there. So just a little bit of learning about these lesions of uncertain malignant potential, which do cause us a lot of bother, particularly in the screening program, but also occasionally, as you've seen here in the symptomatic program as well. If you're not familiar with the B classification, which very much is used in UK and Europe for classifying pathological, for biopsy specimens, B1, it goes B1 to B5, it's not BIRADS, but it's a histological classification. The malignant ones are B5A, which is DCIS, and B5B, which is invasive. So B3 lesions are this group of heterogeneous lesions which carry risk of malignancy ranging from only a few percent up to around 30, 40 percent. Traditionally, we've managed them, as we saw with diagnostic surgical incision, but often that does represent over-treatment. It requires anesthesia, additional surgical scars, and of course, as we've said, potentially a second operation should the lesion turn out to be malignant. And so vacuum incision, certainly in UK practice, is gaining increasing acceptance of a way of managing these challenging lesions to avoid surgery. If anybody wants any more information on this, that's just the UK government screening website, but actually there's a session this afternoon at five o'clock where you'll get some more information about how we're managing these sort of lesions in the UK and Europe. Okay, our final case. This time we're not in the symptomatic practice, we're in screening practice. In the UK, we screen with 2D mammography as part of the national screening program where we screen women every three years. So this lady, she's come for her screening mammogram, a fairly dense background pattern here, nothing particularly actually to see on the oblique projection, but on the CC view, possibly you might be thinking that there's a potential abnormality behind the nipple there, and that's indeed what we call her back force. So we thought there might be a possible distortion there. I say we don't screen with tomo, but at screening assessment, when we bring these ladies back, we tend to do a tomosynthesis study in these circumstances to actually confirm that there's truly a spiculate lesion there, or whether it's a summation. So I'll just show you just a single slice from the DVT rather than the whole study, and you can see there that we've got a little spiculate lesion behind the nipple there. Again, on the 2D, it's confirming the presence of a slight suspicious abnormality there. So at the screening assessment clinic, we're also gonna ultrasound the area, and there's our lesion that we've found, and yes, it looks a little bit suspicious there, so we're gonna do a 14-gauge core biopsy. So we did a 14-gauge core biopsy, put a marker clip in place as well. We're gonna come to the tumor board. This is the biopsy specimen at the tumor board, and we've got some abnormal nuclei here, some quite big nuclei, this is odd mitotic figure, but these tumor cells are infiltrating diffusely through the breast tissue. It's ER positive, so hormone receptor positive, and this is lobular carcinoma. Now I'm not gonna ask you to help me with the management of this, because I'm sure like many of you at this point, we'd probably do an MRI, so that is indeed what we did. So that's hopefully not too controversial, our next management step. So we've done the MRI. I'm just gonna show you the MIP image for time, but oops, sorry, the index lesion is here, so that's the lesion we biopsied, but there's just a couple of other little small nodules more posteriorly within the breast there. So there's a couple of little additional things. So like many of you, when we find these additional things, we sort of, we sigh a bit and groan a bit, but then we need to do something about them, so we bring her back to a clinic, and we have a look at that area again with ultrasound, so we do a second look ultrasound of the area, and that's what we did. So this time, I'm in the clinic, and I'm doing my second look ultrasound. Oh, there's just some enhancement curves to show you that those lesions are a bit suspicious, actually, they have the same enhancement curves as the index tumor. So I've just done my second look ultrasound in the clinic, and I can't find any additional lesions here. What are we gonna do next? I think it's really quite good news here. We certainly need to get some tissue from these, don't you? And that's really important. We need to actually get some tissue from here. We can't just go on and do a wide excision and forget about the lesions equally. We don't want to jump straight into mastectomy. So we need to get some tissue, and yes, a few years ago, or certainly probably last year, we would have gone and had a look, done an MRI-guided biopsy in this circumstance, but we now have contrast-enhanced mammography biopsy available to us. So that's actually been quite an exciting thing for us, and actually means we can bring some of these biopsies back into the breast clinic rather than having to go off and do them in MRI. So, ladies in the clinic, we've done our second look ultrasound. We can't find a lesion, so we can now perhaps go and do a contrast-enhanced mammography biopsy. Because we haven't got a diagnostic contrast-enhanced mammography study for this patient, we do need to, first of all, make sure we can actually see the lesion on CSM. So we did a quick, just a single-view diagnostic CSM. So we just did the CC view, and you inject the contrast agent, you wait two minutes, and then you do your first image. You can see the marker clips that were placed at the time of the initial biopsy of the lesion behind the nipple. There was a bit of a hematoma, which is why one of the clips floated off into the hematoma, which is why she's got a second clip. But actually, on the two-minute image, we can't see that additional lesion. So we did another image at three minutes, and actually, by this point, there does seem to be another lesion appearing behind the first lesion. So it does look there may be another lesion there. So at this point, we can put the biopsy device onto the mammography machine. The radiographer can do a measurement from the nipple to find that. So that's just the lesion that's caught my eye, which looks to correspond with the MRI lesion. Radiographer puts the breast in place. They do the scalp view for the biopsy, so we can see the lesion correctly positioned in the scalp view there. It's done under a stereotactic guidance, so you have a check pair, 15 degrees either side of the vertical. Actually, in reality, when you're doing this, you can toggle between the low energy and the recombined images, so you can check landmarks and stuff. And we actually did a 14-gauge core biopsy here, and you can see the needle within the lesion. And actually, the biopsy result from that was a ductal carcinoma, so actually a different tumor type from the original lobular carcinoma. And the patient actually underwent a mastectomy. So just a brief word about Constantin's breast biopsy. It is a new technique, and it's very useful to us, because I think if the CSM's going to expand, then we do need to have a way of dealing with these lesions that are occult and other imaging modalities. It is a potential alternative to MRI-guided biopsy, and it's quite convenient to be able to bring the biopsies back into the breast units, rather than have to send the lady off to MRI. It also potentially improves patient throughput, because often, actually, in this circumstance, we'd have to send the lady away, book her for an MRI-guided biopsy, which could be a few days or even a week or so later. So it does potentially improve the patient pathway as well, but we do need further work to define protocols and establish efficacy. So that's really all I want to say about those cases, hopefully giving you an idea of how we use contrast transformography in my symptomatic practice in the UK.

breast cancer

contrast-enhanced imaging

MRI

mammography

diagnostic accuracy

treatment planning

tumor biology

multifocal diseases