Contrast-enhanced digital mammo helps avoid benign biopsies

Using contrast-enhanced digital mammography (CEDM) to evaluate low to moderately suspicious breast lesions can greatly reduce biopsies in patients with benign lesions, according to a study published Sept. 5 in Academic Radiology.

Eight radiologists showed “significant” improvement in area under the curve (AUC) scores when using CEDM compared to digital mammography (DM)/ digital breast tomosynthesis (DBT) alone, and DM/DBT with ultrasound. Radiologists also recommended fewer biopsies of benign lesions.

“In clinical practice, the results of this study suggest that CEDM use will likely translate into fewer biopsies in patients with benign lesions and thus could significantly improve (positive predictive value) PPV,” wrote Margarita L. Zuley, MD, with the University of Pittsburgh School of Medicine & University of Pittsburgh Medical Center, and colleagues. “In addition to potentially reducing biopsy rates for benign lesions, which would reduce the ‘harms’ of mammography, CEDM may also offer other benefits including improved patient satisfaction, reduced cost, and improved clinical efficiency.”

A primary criticism of breast imaging is the damage inflicted by the high rate of benign biopsies, Zuley et al. added, most notably from lesions defined as Breast Imaging Reporting & Data System (BI-RADS) 4A (suspected low malignancy) and 4B (moderate suspicion for malignancy). And in the U.S., biopsy PPV is low, while the amount of benign biopsies continues to increase.

In the study, eight radiologists retrospectively and independently analyzed 60 lesions in 54 patients who underwent CEDM. They scored lesions according to BI-RADS for DM/DBT, US and CEDM.

Overall, there were 49 benign, two high-risk and nine cancerous lesions among all women. Radiologists averaged a much higher AUC for CEDM (0.85) than DM/DBT alone (0.66) or US (0.75).

CEDM also improved true positive rates from 0.74 with DB/DBT, and 0.89 with US, to 0.90 when using CEDM. False positives rates were also decreased to 0.39 with CEDM, from 0.47 with DM/DBT and 0.61 with US.

And on average, radiologists had a 21.8% reduction in recommendation for biopsy of actually benign lesions without loss of sensitivity when compared to DM/DBT with US.

“Given that more than one million breast biopsies are performed annually in the United States alone, and that close to 90% of biopsies are performed for low to intermediate risk lesions, the potential impact in terms of number of women benefitting from biopsy avoidance and reduction in cost to society is high,” the researchers concluded.