Technique, protocols and adverse reactions for contrast-enhanced spectral mammography (CESM): a systematic review

Abstract

We reviewed technical parameters, acquisition protocols and adverse reactions (ARs) for contrast-enhanced spectral mammography (CESM). A systematic search in databases, including MEDLINE/EMBASE, was performed to extract publication year, country of origin, study design; patients; mammography unit/vendor, radiation dose, low-/high-energy tube voltage; contrast molecule, concentration and dose; injection modality, ARs and acquisition delay; order of views; examination time. Of 120 retrieved articles, 84 were included from 22 countries (September 2003-January 2019), totalling 14012 patients. Design was prospective in 44/84 studies (52%); in 70/84 articles (83%), a General Electric unit with factory-set kVp was used. Per-view average glandular dose, reported in 12/84 studies (14%), ranged 0.43-2.65 mGy. Contrast type/concentration was reported in 79/84 studies (94%), with Iohexol 350 mgI/mL mostly used (25/79, 32%), dose and flow rate in 72/84 (86%), with 1.5 mL/kg dose at 3 mL/s in 62/72 studies (86%). Injection was described in 69/84 articles (82%), automated in 59/69 (85%), manual in 10/69 (15%) and flush in 35/84 (42%), with 10-30 mL dose in 19/35 (54%). An examination time < 10 min was reported in 65/84 studies (77%), 120 s acquisition delay in 65/84 (77%) and order of views in 42/84 (50%) studies, beginning with the craniocaudal view of the non-suspected breast in 7/42 (17%). Thirty ARs were reported by 14/84 (17%) studies (26 mild, 3 moderate, 1 severe non-fatal) with a pooled rate of 0.82% (fixed-effect model). Only half of CESM studies were prospective; factory-set kVp, contrast 1.5 mL/kg at 3 mL/s and 120 s acquisition delay were mostly used; only 1 severe AR was reported. CESM protocol standardisation is advisable.

Keywords: Breast; Contrast media; Drug-related side effects and adverse reactions; Mammography; Radiation dosage.

Fig. 1

Flowchart of the study selection and exclusion for articles on contrast-enhanced spectral mammography

Fig. 2

Geographic distribution of research groups which published results of clinical applications of contrast-enhanced spectral mammography. From very light blue to dark blue, the number of groups progressively increases from 1 to 7; grey colour means no publications

Fig. 3

Graphical summary of conventionally agreed view acquisition orders for contrast-enhanced spectral mammography: CC craniocaudal view, MLO mediolateral oblique view, L left, R right

Fig. 4

Graphical summary of pathology-oriented view acquisition orders for contrast-enhanced spectral mammography: CC craniocaudal view, MLO mediolateral oblique view, S suspicious breast, NS not suspicious breast

Fig. 5

Forest plot of the 84 analysed articles on contrast-enhanced spectral mammography. No heterogeneity was found among studies (I² = 0%). The last row shows the pooled rate for adverse reactions arising from iodinated contrast agent administration, calculated using the fixed-effect model

Fig. 6

Funnel plot showing risk of publication bias in articles on contrast-enhanced spectral mammography, confirmed by the Egger test (p < 0.001)

Fig. 7

Graphic showing the number of articles published per year regarding contrast-enhanced spectral mammography