Detection of a contralateral breast malignancy using contrast-enhanced mammography (CEM) overlooked by initial MRI scan

Abstract

Contrast-enhanced mammography (CEM) has emerged as a promising technology in the field of breast imaging, experiencing growing acceptance. However, the comparative evaluation of its diagnostic accuracy against MRI remains sparse, largely attributed to its relatively recent introduction. Current studies suggest that MRI and CEM exhibit comparable sensitivity for detecting the index breast lesion. However, there is conflicting evidence regarding their sensitivity in detecting additional breast lesions in cases of known breast cancer, with some studies demonstrating MRI's superiority and others reporting similar sensitivity between the 2 modalities. We present a case where CEM effectively detected a contralateral breast malignancy in a patient with a newly diagnosed breast cancer, whereas it went undetected by MRI initially. Our presentation underscores the importance of more comprehensive research to assess CEM's overall diagnostic capabilities in breast imaging in comparison to MRI, as there may be situations where CEM outperforms MRI.

Keywords: Breast cancer; Contrast-enhanced mammography (CEM); MRI.

Fig. 1

Mammogram: Left craniocaudal (LCC) and left mediolateral oblique (LMLO) views show a 11 mm lesion in the central outer of the left breast (A,B). RCC and RMLO views show a new 4 mm spiculated mass in upper outer quadrant right breast which was initially missed (C,D). Both breasts show BIRADS-C focal asymmetry.

Fig. 2

Left breast tomosynthesis: An 8 mm ill-defined mass in the central outer left breast visualized in LMLO and LCC views (A,B).

Fig. 3

Ultrasound scan: An ill-defined hypoechoic lesion measuring 7 × 2.4 mm is seen in the central outer of the left breast (A). A single enlarged left axillary node is shown with cortical thickness of 4 mm (B).

Fig. 4

CT scan chest/abdomen/pelvis with contrast: Enhancing cancer at upper outer quadrant left breast with 1 enlarged left axillary node. No evidence of distant or bony metastasis was detected on CT.

Fig. 5

NM bone whole body shows no evidence for bone metastases.

Fig. 6

MRI breasts with gadolinium: Left breast T2 shows an intermediate signal lesion 8 × 10 × 10 mm in the central outer left breast with avid contrast enhancement and restricted diffusion on DWI/ADC map; MRI 6 (A). Single enlarged level I left axillary node is seen; MRI 6 (B). A suspicious enhancing 8 mm nodule in the upper central left breast is visualized; MRI 3(C). Right breast shows benign cystic changes. The arrow indicates a subtle enhancing lesion that was identified during a retrospective review (D).

Fig. 7

The long arrow indicates axillary lymph node, and the short arrow indicates known cancerous lesion on CEM (A). The known cancerous lesion exhibits enhancement on LCC view of CEM (B). A new area of enhancement measuring 12 mm is seen in the upper outer quadrant of the right breast (C, D).

Fig. 8

The image indicates a 12 mm hypoechoic lesion that is ill-defined on the ultrasound of the right breast; U5.

Fig. 9

Mammogram after Magseed insertion: The long arrow shows the cancerous lesion in the left breast with Magseed within in the central outer area. The short arrow indicates the coil marker clip in the left upper inner quadrant, which came back as benign. The circle shows the third marker clip in the left upper central associated with B3 lesion (A, B). Right breast: The Magseed and marker clip in the cancerous lesion is seen in the upper outer quadrant right breast (C, D).