Comparative Performance of Contrast-enhanced Mammography, Abbreviated Breast MRI, and Standard Breast MRI for Breast Cancer Screening

Abstract

Background Contrast-enhanced mammography (CEM) and abbreviated breast MRI (ABMRI) are emerging alternatives to standard MRI for supplemental breast cancer screening. Purpose To compare the diagnostic performance of CEM, ABMRI, and standard MRI. Materials and Methods This single-institution, prospective, blinded reader study included female participants referred for breast MRI from January 2018 to June 2021. CEM was performed within 14 days of standard MRI; ABMRI was produced from standard MRI images. Two readers independently interpreted each CEM and ABMRI after a washout period. Examination-level performance metrics calculated were recall rate, cancer detection, and false-positive biopsy recommendation rates per 1000 examinations and sensitivity, specificity, and positive predictive value of biopsy recommendation. Bootstrap and permutation tests were used to calculate 95% CIs and compare modalities. Results Evaluated were 492 paired CEM and ABMRI interpretations from 246 participants (median age, 51 years; IQR, 43-61 years). On 49 MRI scans with lesions recommended for biopsy, nine lesions showed malignant pathology. No differences in ABMRI and standard MRI performance were identified. Compared with standard MRI, CEM demonstrated significantly lower recall rate (14.0% vs 22.8%; difference, -8.7%; 95% CI: -14.0, -3.5), lower false-positive biopsy recommendation rate per 1000 examinations (65.0 vs 162.6; difference, -97.6; 95% CI: -146.3, -50.8), and higher specificity (87.8% vs 80.2%; difference, 7.6%; 95% CI: 2.3, 13.1). Compared with standard MRI, CEM had significantly lower cancer detection rate (22.4 vs 36.6; difference, -14.2; 95% CI: -28.5, -2.0) and sensitivity (61.1% vs 100%; difference, -38.9%; 95% CI: -66.7, -12.5). The performance differences between CEM and ABMRI were similar to those observed between CEM and standard MRI. Conclusion ABMRI had comparable performance to standard MRI and may support more efficient MRI screening. CEM had lower recall and higher specificity compared with standard MRI or ABMRI, offset by lower cancer detection rate and sensitivity compared with standard MRI. These trade-offs warrant further consideration of patient population characteristics before widespread screening with CEM. Clinical trial registration no. NCT03517813 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Chang in this issue.

Graphical abstract

Figure 1:

Cohort selection diagram. GFR = glomerular filtration rate.

Figure 2:

Bar charts of each performance metric summarize examination-level performance by modality, with P values indicating significant differences. ABMR = abbreviated breast MRI, CDR = cancer detection rate, CEM = contrast-enhanced mammography, PPV₂ = positive predictive value 2 (of biopsy recommendation).

Figure 3:

Contrast-enhanced mammograms (CEMs; A, B) and MRI scan (C) with true-positive findings in a 73-year-old participant with personal history of right breast ductal carcinoma in situ treated with lumpectomy and newly diagnosed left breast invasive lobular carcinoma (not shown), who presented for contralateral right breast screening. (A) Mediolateral oblique low-energy and (B) mediolateral oblique recombined CEMs of the right breast show an irregular contrast-enhanced mass with irregular margins in the upper outer quadrant (arrows). (C) Axial contrast-enhanced breast MRI sequence shows an irregular contrast-enhanced mass with irregular margins that is suspicious for cancer in the upper outer quadrant of the right breast (arrow). Pathology revealed recurrent invasive ductal carcinoma and ductal carcinoma in situ, Nottingham grade I, that was estrogen receptor positive, progesterone receptor positive, and human epidermal growth factor receptor 2 receptor negative.

Figure 4:

Contrast-enhanced mammograms (CEMs; A, B) and MRI scan (C) show a false-positive finding in a 63-year-old participant with newly diagnosed screen-detected right breast ductal carcinoma in situ; the patient presented for contralateral left breast screening. (A) Mediolateral oblique low-energy and (B) mediolateral oblique recombined contrast-enhanced images of the left breast show an oval enhancing mass with irregular margins in the upper outer quadrant (arrows). (C) Axial contrast-enhanced breast MRI scan shows a 6-mm oval mass with irregular margins in the upper outer quadrant of the left breast (arrow). Pathology from MRI-guided biopsy showed florid sclerosing adenosis.

Figure 5:

Contrast-enhanced mammograms (CEMs; A, B) and MRI scan (C). CEM shows a false-negative finding and MRI/abbreviated breast MRI scan shows a true-positive finding in a 61-year-old participant with partner and localizer of breast cancer gene 2, or PALB-2, mutation and remote history of benign needle biopsy in the left breast presenting for high-risk screening. (A) Mediolateral oblique low-energy and (B) mediolateral oblique recombined images of the left breast from the CEM reported as Breast Imaging Reporting and Data System (BI-RADS) category 2 (benign). (C) Axial contrast-enhanced breast MRI scan shows 31-mm nonmass enhancement in the inferior left breast reported as BI-RADS category 4 (arrow). Pathology from MRI-guided biopsy revealed ductal carcinoma in situ and final surgical pathology revealed invasive ductal carcinoma with ductal carcinoma in situ, Nottingham grade III, estrogen receptor positive, progesterone receptor negative and HER-2 receptor positive.

Figure 6:

Contrast-enhanced mammograms (CEMs; A, B) and MRI scan (C). CEM true-negative finding and abbreviated breast MRI/standard MRI with false-positive findings in a 25-year-old participant with left breast nipple discharge. (A) Mediolateral oblique low-energy and (B) mediolateral oblique recombined images of the left breast from the CEM reported as Breast Imaging Reporting and Data System (BI-RADS) category 1 (negative). (C) Axial contrast-enhanced breast MRI scan shows 9-mm focal nonmass enhancement in the inferior left breast reported as BI-RADS category 4 (arrow). Pathology from MRI-guided biopsy revealed breast parenchyma with dense fibrous stroma and focal fragment of cyst wall.