 Thank you, Shilpa once again. Why do we need contrast imaging in Brest? A little bit on why we need a contrast imaging. We talked about contrast MRI and then we are now on contrast mammography and we'll see why we need contrast imaging at all. And we will see the technique of CEDM indications and the practical applications with case examples. And finally, I would conclude with the advantages and limitations of contrast enhanced mammography. As we all know, breast cancer can present as a mass whether it can be speculated or non-speculated. You can have calcification within the ducts. You can have non-calcified DCIS seen as soft tissue within the duct. You can see malignancy presenting as isolated architectural distortion or sometime even as subtle asymmetries. But why cancers are missed? In case of a dense breast as we all know in mammography because of superimposition of tissue and a small cancer when it does not produce any surrounding architectural distortion or when they do not have a speculated margins. And cancers can mimic just as a glandular tissue, for example, in case of a lobular carcinomas, non-calcified DCIS and sometimes because of the location. So what does contrast imaging do? To pick up these difficult cancers are it totally takes out the background superimposed tissue and the cancer tissue stands out as an enhancing mass or an abnormality. So we have two contrast studies in breast imaging that's been widely used. One is a contrast enhanced MRI and the second is the contrast enhanced mammography. Let's see why breast cancers enhance because we know that the breast cancer develops new vascularities and because of the leaky capillaries, they enhance very fast in the first two minutes. And because of the leaky capillaries, the enhancement also washes out much earlier than a benign tissue. And the next thing that we have to look at it, do we really need a contrast study? We have digital mammography, we have tomosynthesis, we have an ultrasound, but do we really need a contrast imaging in breast? And this study really emphasise on the role of contrast imaging. Though it says about the MRI versus the conventional mammography, the same thing applies for the contrast enhanced mammography as well. As you can see in the graph, the detection rate of the malignancies when aggressive are much more higher when we use a contrast imaging compared to the mammogram and the interval cancers that's been picked up or detected is also much higher in the MR or the higher grade spectrum. So in case of a low grade DCIS, mammogram actually is very close to the MRI. But when you see the higher grade invasive cancers and you can see the difference between the mammogram and the MRI is very, very high. That is because MR or any contrast study picks up an aggressive malignancy. In a contrast enhanced mammography, we use two sets of imaging. One is the low energy image and second is the high energy image. The soft tissue is better visualised at 30 kV x-ray which is the low energy and the iodine is best visualised at 50 kV x-rays. So when we do a low energy imaging, what we see is something very similar to a two-dimensional mammography. The high energy image is not readable and you see everything completely white and what the system post-processes and gives us is the recombined image where the background tissue is completely suppressed and only the enhancing masses are or the non-mass abnormalities are well visualised in the contrast enhanced mammography on recombined image. So what really happens is you can see an abnormality as a speculated mass or a non-speculated mass, a calcification or a non-calcified DCIS or an architectural distortion. On a contrast enhanced mammography, everything is seen and the recombined image basically suppresses the whole background parankamal tissue and all the enhancing abnormalities be it a non-speculated mass or a speculated mass, calcified, non-calcified DCIS or an enhancing architectural distortion all stands out very well for us in a recombined image. So if I have to ask you which side is the abnormality in this patient, if I do not give a clinical history, it is extremely difficult for us to guess which side has got the pathology in this extremely dense mammogram. But contrast makes our life much, much simpler because the parankamal is completely suppressed and you can see an extensive multifocal, multi-centric malignancy here and enhancing abnormal load and you can see a non-enhancing cyst also on the opposite breast. So this is what in a simple words contrast enhanced mammography does to us. So what is the role of a radiologist in the evaluation of breast cancer? One is to detect a non-palpable abnormality or a non-palpable early breast cancer through screening and when you have a palpable abnormality, we do a diagnostic imaging to characterize this palpable abnormality and if a diagnosis of cancer is made, imaging is done to perform the local staging for the breast cancer and for women who undergo post a new adjuvant chemotherapy, imaging is performed to assess response to the treatment and finally surveillance on an imaging of treated cancer. So the role of CEM is very well in screening, staging, response, assessment and sometimes in problem solving. If you see the indications of MRI and CEM, they are pretty much the same because the principle of imaging is also the same which is the contrast enhancement. So let's see first the role of CEM in screening. So this is a 46 year old lady, very dense breast, no complaints for screening. On the right breast, what we observe is an area of isolated architectural distortion. So the contrast shows an enhancing abnormality corresponding to the architectural distortion but there are also few more abnormal enhancement seen adjacent to the enhancing architectural distortion. So the area of architectural distortion seen on the mammogram and the contrast enhanced mammogram, if you compare, this is much bigger. We have an ultrasound correlate which also shows hard peripheral stiff rim on elastography. So this was biopsy and this was a multifocal lobular carcinoma. So on a screening, we detected an architectural distortion and contrast helped us that this architectural distortion is definitely abnormal by showing a wider area of enhancement and also picked up an additional foci which is very common that we see on lobular carcinomas. So there were several studies, the use of CEM in screening though is not coming to the guidelines. There were several studies which had compared the role of CEM with MRI, role of CEM and a supplementary ultrasound where the performance of contrast enhanced mammography was definitely comparable. The second component which I personally feel that CEM has a definitely a potential role in developing countries like this is the role of CEM in local staging. So what is the role of imaging in local staging? First and foremost is we need to identify whether the abnormality that we see or a palpable abnormality is represent a unifocal cancer or a multifocal cancer. If it's unifocal, what is the actual extent of abnormality if at all the women is undergoing a breast conservation surgery and third is a nodal status and fourth is a contralateral screening. So let's see examples of one after the other. This is a 41-year-old lady, pretty young lady who comes with a palpable right breast lump. So this corresponds to her palpable abnormality and it is really scary to see whether young lady, dense breast, she has got a cancer whether she is an isolated unifocal or whether she has got multifocal cancer. So contrast makes it very, very simple to us that we know that this is a unifocal invasive malignancy one and you will be able to define the extent that this is an isolated. There is no non-mass associated enhancement and most importantly in young women the contralateral breast is normal as well. So this serves as a one-stop solution for us in doing the local staging when provided we also do an ultrasound to stage the axilla. Now, sorry the age is not mentioned, I guess she is also a pre-menopausal less than 50-year-old lady with a left breast lump. As you can see this mammogram clearly shows you the abnormality seen in the upper inner quadrant of her left breast. Closer view shows there are calcifications, coarse heterogeneous calcifications and if you find rheomorphic calcifications seen within the mass there is no other abnormality noted. Now look at the contrast-enhanced mammogram. So we see an in the mass which is also showing a heterogeneous enhancement on contrast plus you can see a non-mass enhancement extending from this mass towards the nipple for a distance of more than 2 centimeters. So if the lady had undergone a breast conservation surgery without a contrast imaging she would definitely have a positive margin in her lumpectomy specimen because she has quite a bit of non-mass enhancement which is a non-calcified DCIS extending from the mass towards the nipple in segmental distribution. So this is here contrast mammography had helped us in defining the extent of the abnormality so that the surgeon can plan his surgical margins better. So we avoid a resurgery which is very very important to us because most of our patients are paying from their own pocket and this actually avoids an unnecessary mastectomy and an additional resurgery. And this is the MRI which shows the similar finding that the surgeon had modified his margins and have included the non-mass abnormality as well and the final pathology was an invasive carcinoma with the DCIS. Moving on to the third example a 52-year-old lady with right breast limb again a heterogeneously dense breast but it's very clear to see this speculated mass seen in the upper outer quadrant of her right breast and a contrast was performed for her. As you can see there is there are some calcifications which are also extending to her anteriorly from this speculated mass on these spot views. Look at the contrast you see extensive additional focus you see multifocal multi-centric cancer is almost occupying whole of her right breast plus we also could pick up an another enhancing focus or enhancing mass in the left breast in the lower central or lower inner quadrant of her left breast. So we didn't target at ultrasound we could localize all these multifocal cancers on the right breast and also this was the left breast enhancing mass seen on the contrast enhanced mammography. So the MRI also showed the same this was the enhancing mass which was seen on the contrast mammography and the final pathology was multifocal invasive ductile carcinoma with extensive dciers and the left breast was a complex chlorosing lesion. When we look at the local staging when it comes to the nodal staging CEM is not the right modality as we all know mammogram is not the right modality but CEM plus ultrasound is definitely comparable to ultrasound and a good axillary ultrasound can very well pick up all the lymph nodes from level 1 to 3 and intramammary and supra clavicular nodes also in selective cases. So this was the study these are the studies which had said that you know there is a comparable performance of an axillary ultrasound and the standard breast MRI. So CEM though is not the modality of choice to do the axillary staging in the local staging we never stop with the mammogram we do an ultrasound for these patients and a good axillary ultrasound can definitely stage the axilla. So the third component of the role of CEM is the response assessment. This is a 51 year old lady with right breast lump as you can see she has got a speculated mass in her upper outer sorry outer central quadrant of her right breast plus on a closer look we also see a lot of microcalcifications extending along the biopsy was an invasive carcinoma and she was a herd to enrich tumor as is also pointers towards it which shows extensive microcalcifications. This was the post chemotherapy mammography which shows completely complete response the total the total disappearance of this speculated mass but we had calcifications to localize. So this is the pre adjuvant new pre new adjuvant CEM and the MRI which shows comparable so these are the calcifications which show which is seen as non mass enhancement on the pre new adjuvant CEM and also on MRI and this was the post new adjuvant CEM and MRI which also is comparable saying that there is a complete response but there is one advantage here in the CEM using CEM for the new adjuvant chemotherapy response because these this patient had got microcalcifications extending posterior to the mass and also anterior to the mass and we use this as a marker to localize the lesion. So we did not clip this lesion this mass because we know though she is undergoing a new breast conservation surgery following a new adjuvant chemotherapy we know that the calcifications persist and hence we did a bracketing technique and there were foci of DCIS with no residual invasive carcinoma and the receptive margins were free of tumor and this was the specimen with bracketing. So look at this case this was a 45 year old lady with right breast lump she was a triple negative with an axillary node metastasis and hence she underwent a new adjuvant chemotherapy and this was the contrast enhanced mammography which shows one additional focus which is enhancing which is also seen on ultrasound and MRI and this is the pre neo adjuvant and this was the enhancing node so we clipped both the lesion and the lymph node and this was the post neo adjuvant chemotherapy which still shows some persistent mass and the clip is seen here and here as well and what is very interesting to see is on an ultrasound we see a soft tissue mass with a clip inside but if you see the enhancing component is restricted to the posterior aspect of the mass and not in the clip the clip was positioned in the center of the mass and the anterior aspect of the mass was not enhancing at all and the same finding was seen on MR as well so the prediction of the active or the residual disease was comparable to MRI and was also seen on histopathology confirmed so this was a mass which was clipped you can see that the masses the clip was placed in the center of the mass and this was the node positive node which was also clipped and we put in a wire in the axillary lymph node and targeted axillary dissection with sentinel node dissection and the excision lumpectomy was done and the pathology also confirmed that the residual mass was seen in the posterior to the clip there were several studies systematic reviews which also compares there you cannot we don't have a standardization for you can't compare the performance of CEM with a digital mammography what we can compare is CEM can be compared with MRI because the technique is the same both uses contrast and in many papers and systematic reviews this was definitely comparable the last part is though it is not clearly defined as one of the indications in our day-to-day clinical practice we had used CEM as a problem solving tool as well this was a 42-year-old lady with pain in the right breast and she also had a lump in the left breast which she says that she has not bothered she has been having it for two or three years what she had in the right breast was a pyridictal mastitis and what she had in the left breast though it looked like a circumscribed mass it was quite big palpable and she was 42 so we decided to biopsy but there was absolutely no enhancement of this mass and this was a solid mass as well so this is a solid mass with no enhancement and the MR was performed purely for academic reasons to compare and the final biopsy was pseudo angiomata stromen hyperplasia or the PASH so this was big mass no enhancement we know that this will cannot represent an invasive cancer the last component last case example is a 65-year-old lady with back pain she who had vertebral metastasis and PET CT was done to localize her primary as you can see that axillary node supraclavicular nodes on the right side is lighting up she has got liver lesion she has got a vertebral metastasis she has got a rib metastasis all lighting up on PET and so she was referred to us for the mammogram and you can see there were large lymph nodes with perinodal extension and hence she had trabecular thickening and periareola skin thickening all secondary to this nodal mass and this was a scattered breast we did not see any suspicious microcalcifications or mass we gave contrast and you can see that there is definitely multiple small irregular masses with indistinct margins which were not seen on the as you can see there is no corresponding enhancement seen on the opposite side and we did a targeted ultrasound we could localize such smaller lesions and this is actually a node with perinodal extension and this mass was definitely showing very hard on elastography and we biopsied this and this was proven to be an invasive carcinoma with a metastatic right axillary lymph node with extensive perinodal extension and that explains her extensive metastasis as well so though it looks so exciting when I had shown you a lot of examples this modality is not without any limitation as we use the same mammographic technique the location of the lesion cannot be well brought out just because we are doing a contrast mammography this was a 59-year-old lady with a left breast lump as you can see how much ever our technologist tried to do an excellent positioning it is impossible to visualize because of the location of the mass in the left breast so she even tried a cleavage view the contrast so nothing was helpful for us because of the location of the lesion the pathology was infiltrating Dr. Carcinoma and she was ERPR positive luminal B and here we definitely need MR MR cannot be avoided because MR because it is not limited by the location of this lesion we will be very sure to say whether the chest wall involvement is seen whether it is just infiltrating the pectoralis major or it is just sitting on the pectoralis major without an obvious infiltration so this positioning limitation cannot be overcome just because we are giving a contrast on a mammography and the most important question that we get in our mind is how much more is the radiation when we use a CEDM and as you can see this is the article which talks about sorry yeah which talks about the average glandular dose when we use CEDM when we use a digital mammography and the the tomosynthesis and it is found that it is there is definitely an increase in the radiation dose compared to the digital mammography and the tomosynthesis however it is when you combine 2d plus 3d if you use only CEDM and use the low energy x-rays as 2d it is definitely less and even if you do CEDM the average glandular dose falls below the limit of 3mg set by the mammographic quality standard at regulation and hence we should not think too much about the radiation it is definitely within the acceptable limits provided you use them wisely so that the last part of the talk is what is the advantage we talked about the limitation we talked about the radiation that's involved and how far how better or how it is not better compared to the MRI when we have when we look at the MRI the most important advantage that we have is no radiation contrast reactions are less life-threatening it is not limited by the positioning but the we also have to remember that it is a totally different study it is time consuming you cannot use it for claustrophobic patients it is not widely available it is definitely expensive and theoretically it has much more false positive rates compared to the contrast enhanced mammography whereas contrast enhanced mammography though it has got an ionizing radiation we use an iodinated contrast it is not possible to completely evaluate when the mass is seen in the difficult location it definitely has significant advantage in and we can be using it for a vast group of patients because it is simple it's quick relatively cheap same equipment as a mammogram and it can be completed as one study you don't have to schedule the patient for contrast study after the biopsy reports for MRI and theoretically it is said that it gives less false positive and when everything is done in one go it is definitely more comfortable to the patient and also for us so to conclude contrast enhanced mammography definitely has a role in local staging with a diagnostic accuracy comparable to MRI in most of our clinical situations because it is cost effective and acts as a one-stop solution