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Titanium Contrast Enhanced Mammography (TiCEM) with 50° Wide-Angle HD Breast Tomosynthesis


Ain Shams University Specialized Hospital, Radiology Department, Egypt

Hossam El Farghaly

|2020-01-02

The use of contrast agents is a common practice in radiology. For example as used in CT, MRI and US. The purpose of injecting a contrast agent is to increase the visibility of vascular structures or to visualize contrast agent uptake in tissues. As Contrast Enhanced Dual Energy Mammography(CEDEM) is implemented on a standard mammography system, the high-energy (HE) and low-energy (LE) images must be acquired successively. With the introduction of the MAMMOMAT Revelation, Siemens Healthineers has implemented its CEDEM application ‘Titanium Contrast-Enhanced Mammography (TiCEM)’ which aims at improving diagnostic accuracy in the detection and characterization of breast tumors, by incorporating functional information.

The clinical workflow for a TiCEM examination starts with the injection of the contrast agent by means of a power injector. At the time of injection, the breast is not yet compressed to allow for normal tissue perfusion and unhindered inflow of the contrast agent into the breast. The dosage of the contrast agent is typically weight-dependent and varies between institutions. After a waiting time of approximately 2 minutes, the woman is positioned at the MAMMOMAT Revelation and the breast is compressed. Then, a low-energy (LE) and a high-energy (HE) image are acquired successively and a recombined image of that view called an Insight CEM image is calculated. These steps are then repeated for each additional view, without the need to perform a new contrast agent injection. The time window for performing multiple views with a single contrast agent injection lasts up to 10 minutes, although the views should be acquired without any unnecessary delays. The order in which the views are acquired seems to be of little clinical significance and does not appear to affect image quality. Care should be taken when handling the contrast agent to avoid contamination of the detector or the skin with pure contrast agent, as this might mimic calcifications or result in artifacts.

In breast care, Tomosynthesis technology – also known as three-dimensional (3D) mammography, revolutionizes diagnostic mammography. Tomosynthesis technology is slated to soon take over Full Field Digital Mammography (FFDM) by means of improved diagnostics, better image quality, reduced recall rates, workflow etc. Tomosynthesis technology creates an impact in almost every aspect of breast imaging from diagnostic breast cancer screening to interventions. It helps us to reduce the recall rate and false positive rates, irrespective of a women’s age or breast density.

History

Patient is a 52-year-old female, presented for screening. No personal or family history of breast cancer or any other cancer.

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2D and Insight 2D Images


Clinical Evidence – TiCEM with 50° wide-angle HD Breast Tomosynthesis.



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Clinical findings 

ACR density, heterogeneously dense breasts with a right side UOQ rounded shaped partly well circumscribed partly obscured margin mass.

RI showed the mass to intensely heterogeneously enhancing 2 cm in diameter yet, detected another smaller enhancing mass 6 mm in diameter, 2 cm away from the index mass. US confirmed those findings and guided for a micro biopsy.

Impression: Multifocal breast disease.

Conclusion

High depth resolution is key for tissue separation in 3D mammography. Siemens Healthineers pioneered the 50° wide-angle HD Breast Tomosynthesis, reaching the highest depth resolution on the market (3.5 times higher depth resolution compared to narrow angle systems) and Titanium Contrast Enhanced Mammography (TiCEM) with its unique HE spectrum and an optimized titanium filter, which reduces X-ray tube load to enable seamless examinations. TiCEM delivers additional diagnostic information for more confident decision-making and helps to detect or rule out lesions. Being an integrated functionality of the Siemens Healthineers MAMMOMAT Revelation, TiCEM can help reduce scheduling conflicts and workload on other modalities making it a cost effective alternative to breast MRI. Finally, guidelines are needed to achieve international standards in acquisition techniques and image interpretation.

References

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2. Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U et al. (2013) Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology 267(1): 47–56.


3. Friedewald SM, Rafferty EA, Rose SL, Durand MA, Plecha DM, Greenberg JS et al. (2014) Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA 311(24):2499–507.


4. Lång K, Andersson I, Rosso A, Tingberg A, Timberg P, Zackrisson S (2016) Performance of one-view breast tomosynthesis as a stand-alone breast cancer screening modality: results from the Malmo Breast Tomosynthesis Screening Trial, a population-based study. European radiology 26(1):184–90.


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6. Strijkers GJ, Mulder WJM, van Tilborg GAF, Nicolay K (2007) MRI contrast agents: current status and future perspectives. Anti-cancer agents in medicinal chemistry 7(3):291–305.


7. Calliada F, Campani R, Bottinelli O, Bozzini A, Sommaruga MG (1998) Ultrasound contrast agents: basic principles. European journal of radiology 27 Suppl 2: S157-60


8. Tofts PS, Brix G, Buckley DL, Evelhoch JL, Henderson E, Knopp MV et al. (1999) Estimating kinetic parameters from dynamic contrast-enhanced T (1)-weighted MRI of a diffusable tracer: standardized quantities and symbols.

Journal of magnetic resonance imaging JMRI 10(3):223–32.


9. Parker GJM, Buckley DL (2005) Tracer Kinetic Modelling for T1-Weighted DCEMRI.  In: Jackson A, Buckley DL, Parker GJM (eds) Dynamic ContrastEnhanced Magnetic Resonance Imaging in Oncology. Springer-Verlag Berlin Heidelberg. Berlin Heidelberg, pp 81–92.