Breast Imaging · Short Report AJR:217, October 2021 www.ajronline.org | 855 Molly B. Carnahan, MD 1 , Barbara Pockaj, MD 2 , Victor Pizzitola, MD 1 , Marina E. Giurescu, MD 1 , Roxanne Lorans, MD 1 , William Eversman, MD 1 , Richard E. Sharpe, Jr., MD, MBA 1 , Patricia Cronin, MD 2 , Bhavika K. Patel, MD 1 Contrast-Enhanced Mammography for Newly Diagnosed Breast Cancer in Women With Breast Augmentation: Preliminary Findings Carnahan et al. CEM for Breast Cancer in Women With Breast Augmentation Breast Imaging Short Report Carnahan MB, Pockaj B, Pizzitola V, et al. Submitted: Dec 16, 2020  Revision requested: Jan 4, 2021  Revision received: Feb 14, 2021  Accepted: Mar 5, 2021  First published online: Mar 17, 2021 B. K. Patel has given educational webinars on implementation of contrast-enhanced mammography for Hologic, with honoraria sent to Mayo Clinic directly, and receives research funding from GRAIL Inc. and Hologic, with monies directed to Mayo Clinic. The remaining authors declare that they have no disclosures relevant to the subject matter of this article. Based on a presentation at the San Antonio Breast Cancer Symposium 2020 virtual annual meeting. Contrast-enhanced mammography (CEM) is an emerging breast imaging technique that uses iodine to highlight areas of tumor neovascularity and has been shown to have sensitivity and specifcity similar to those of contrast-enhanced MRI in the diag- nostic setting [1–3]. To our knowledge, the use of CEM in women with breast augmentation has not been evaluated. In the pres- ent study, we assessed the concordance between CEM and MRI in women with breast cancer and breast augmentation. Methods This HIPAA-compliant retrospective study was approved by the institutional review board at Mayo Clinic Arizona, which waived in- formed consent. Women with newly diagnosed breast cancer who underwent both CEM and MRI were included. A search of an insti- tutional database of 2215 women who underwent CEM between January 2015 and March 2020 identifed 67 women with breast im- plants. Of these, we excluded 40 women without a corresponding MRI examination, three without breast cancer, one who had only axillary disease, and six who received neoadjuvant chemotherapy before CEM or MRI, resulting in a fnal sample of 17 women (six with nondense breasts and 11 with dense breasts; mean [± SD] age, 52 ± 7 years). All CEM and MRI examinations were ordered as part of the diagnostic evaluation of new cancers performed at the discretion of the referring physician and were performed within 30 days after biopsy; CEM was performed frst for eight patients, MRI was per- formed frst for six patients, and CEM and MRI were performed on the same day for three patients. No examination was performed to evaluate implant-related anaplastic large cell lymphoma [4]. The institutional CEM and MRI protocols have been described elsewhere [3]. All CEM examinations included implant-displaced Eklund views, which were obtained by pushing the implant to- ward the chest wall and pulling the breast tissue forward, allow- ing better compression and improved visualization of tissue com- pared with non–implant-displaced views. Although the frst two CEM examinations also included standard mammographic views, these views were no longer obtained beginning in November 2015 because of signifcant artifact (Fig. 1A). Areas of suspicious enhancement on CEM underwent ultrasound-guided, stereotac- tic-guided, or MRI-guided biopsy. All breast imaging was clinically interpreted by one of fve fellowship-trained breast radiologists with 5–14 years of expe- rience, although none of the radiologists had experience with CEM before 2015. Background parenchymal enhancement was characterized on MRI and CEM using BI-RADS criteria. Analysis was based on imaging reports. Information was extracted from the institutional database and electronic medical record and was summarized descriptively. Results Index cancer histology was invasive ductal carcinoma in 15 women (88%), invasive lobular carcinoma in one woman (6%), and ductal carcinoma in situ in one woman (6%). The median size of the index cancer was 2.0 cm (range, 0.7–15.0 cm; three cancers were < 1 cm). Two index cancers (12%) were mammographically occult. CEM and MRI were concordant for the index cancer in all 17 women (Figs. 1B and 1C). Six additional lesions (three multifo- cal, one multicentric, and two contralateral) were observed on CEM and confrmed by MRI in six women (35%). Two of these six additional lesions revealed malignant histopathology (one inva- sive ductal carcinoma and one invasive lobular carcinoma); both additional cancers were mammographically occult and altered the surgical procedure. The four other additional lesions observed us- ing both modalities were found to be benign on biopsy (one ade- nosis, two fbroadenoma, and one lobular carcinoma in situ). MRI did not identify any additional cancers not identifed on CEM. One additional benign lesion (atypical ductal hyperplasia in the contra- lateral breast) was seen on MRI only. Background parenchymal en- hancement was concordant between CEM and MRI in 16 women (94%; minimal or mild on both CEM and MRI in 14 women, moder- ate or marked on both CEM and MRI in two women, and minimal or mild on CEM but moderate or marked on MRI in one woman). Discussion Among 17 women with breast augmentation, CEM (performed using implant-displaced Eklund views) and MRI were concordant doi.org/10.2214/AJR.20.25341 AJR2021;217:855–856 ISSN-L0361–803X/21/2174–855 ©AmericanRoentgenRaySociety In 17 women with newly diagnosed breast cancer who un- derwent contrast-enhanced mammography (CEM) and MRI, both modalities were found to be concordant for the index cancer. In six of the 17 women, CEM showed an additional le- sion that was confrmed by MRI. Of these six additional le- sions, three were multifocal, one was multicentric, and two were contralateral; two of the six were malignant. MRI did not identify any additional cancers that were not identifed on CEM. CEM may have a role in women with breast augmen- tation and either a contraindication or limited access to MRI. 1 Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054. Address correspondence to M. B. Carnahan (Carnahan.Molly@mayo.edu). 2 Department of Surgery, Mayo Clinic Arizona, Phoenix, AZ. Downloaded from www.ajronline.org by 3.238.29.207 on 09/24/21 from IP address 3.238.29.207. Copyright ARRS. For personal use only; all rights reserved