Artefacts in contrast enhanced digital mammography: how can they affect diagnostic image quality and confuse clinical diagnosis?

Abstract

Contrast-enhanced digital mammography (CEDM) is a diagnostic tool for breast cancer detection. Artefacts are observed in about 10% of CEDM examinations. Understanding CEDM artefacts is important to prevent diagnostic misinterpretation. In this article, we have described the artefacts that we have commonly encountered in clinical practice; we hope to ease the recognition and help troubleshoot solutions to prevent or minimise them.

Keywords: Artefacts; Artifacts; Breast cancer; Contrast-enhanced digital mammography (CEDM); Contrast-enhanced spectral mammography (CESM).

Fig. 1

Motion artefact. A ductal carcinoma in situ was diagnosed in the left breast after an ultrasound-guided core needle biopsy. CEDM was performed for preoperative staging. a The LE image shows a post-biopsy hematoma with a marker (arrow). b The recombined CEDM image demonstrates that the margins of the hematoma are blurred secondary to motion artefacts. Some black bands are visible (arrowhead), and the post-biopsy marker appears to be in a different position from the previous image (arrow). c A new recombined CEDM image was performed. Here, the motion artefacts are no longer visible, and the marker appears to be in the right position (arrow)

Fig. 2

Hair artefact. CEDM was performed for preoperative staging in a 51-year-old patient. a The recombined image shows several curvilinear lines related to the patient’s hair (arrow). b Thus, we asked the patient to tie her hair before performing another acquisition. The artefact is no longer visible (arrow)

Fig. 3

Antiperspirant artefact. CEDM was performed for staging an IDC in the right breast of a 59-year-old woman. a Left MLO tomosynthesis shows a little white spot in the axillary region caused by the presence of the antiperspirant substance (circle). b The CEDM-recombined image demonstrates that antiperspirant is barely perceptible as a small, black dot (circle)

Fig. 4

Air trapping artefacts: A CEDM performed for problem solving in a 52-year-old woman, using a (a) CEDM-recombined image and (b) LE image. Both images demonstrate the presence of a vertical, black band (arrows) secondary to trapped air

Fig. 5

Contrast splatter. CEDM was performed in a 55-year-old woman for preoperative staging. a The recombined image shows an avidly enhancing lesion in the outer quadrant (arrowhead). b A delayed acquisition was performed where contrast contamination of the skin is visible (arrow). Contrast washout is also demonstrated within the lesion (arrowhead)

Fig. 6

Transient retention of contrast in blood vessels: a CEDM was performed in a 66-year-old woman to evaluate a suspicious finding in the left breast on mammography. a The right, recombined image shows a bolus of contrast within a blood vessel (arrows); b this artefact disappeared is less promiscuous in the following CEDM acquisition (arrow)

Fig. 7

Artefact due to the presence of post ultrasound guided biopsy markers: a LE CEDM image. There are some markers seen at the outer quadrant of the left breast (arrow); b in the recombined image, the markers are seen as high attenuation structures and they demonstrate a surrounding dark halo

Fig. 8

Breast implant artefact. A CEDM was performed for suspected microcalcifications in a 55-year-old woman with a right breast implant. a LE CEDM image shows a breast implant in situ. b CEDM recombined image presents a significant post-processing artefacts secondary to the presence of the implants

Fig. 9

Negative contrast enhancement. a CEDM recombined image presents an irregular, tubular structure (arrow), which is black in relation to the surrounding background. b In LE CEDM image, this wavy band corresponds to a calcified blood vessel (arrow)

Fig. 10

Halo artefact in a 52-year-old woman. a The LE CEDM image demonstrates a dense breast with no show focal alterations, and (b) the recombined image presents an apparent “breast-within-a-breast” artefact (arrow). The skin artefact that is observed in the right breast (arrowhead) is caused by detector saturation in the skin region due to a high detector signal

Fig. 11

Ripple artefact. CEDM performed for preoperative staging. The arrowheads are indicating the ripple artefact, which are seen as thin alternate dark and light lines in the recombined image (a). The artefact is more visible in the magnified view (b, arrowheads)

Fig. 12

Misregistration artefact. A woman with a history of previous right quadrantectomy. a CEDM recombined image shows post-surgical clips with alternating bright and dark lines (arrow). b The same clips are also visible in LE CEDM images (arrow)

Fig. 13

Skin-line artefact. a The early-recombined image demonstrates a marked enhancement of the skin line. b The skin enhancement is not appreciated in the delayed recombined CEDM acquisition

Fig. 14

Enhancement of skin lesions. a The recombined image demonstrates a small oval enhancing lesion in the upper quadrant of the right breast, which could mimic a small enhancing mass (arrow). b The LE CEDM image shows an oval hyperdensity formation in the upper quadrant. Evaluation of the patient’s skin in this region confirmed the presence of a small skin angioma

Fig. 15

Ghosting artefact: a 50-year-old woman presented with a right breast lump. a The LE CEDM image shows no obvious artefacts, and (b) ghosting of the latent CC view (arrowhead) of the previously imaged breast is projected within the MLO image and an axillary line artefact (arrow) is also evident in this image