Original Investigation|Articles in Press

Breast Imaging Reporting and Data System and Contrast Enhancement Mammography: Lesion Conspicuity Likelihood of Malignancy and Relationship With Breast Tumor Receptor Status.

Published:March 08, 2023DOI:

      Rationale and Objectives

      The new version of the Contrast Enhanced Mammography (CEM) Breast imaging Reporting and Data System (BIRADs) encourages investigations of a new enhancement descriptor: “Lesion Conspicuity” (LC). The study aims to assess the diagnostic performance and the relationship with the receptor profile of this new enhancement descriptor.

      Materials and Methods

      Three hundred twenty-five patients with 381 breast lesions who underwent CEM before histological assessmentwere selected. Four radiologists, blinded to each other, categorized LC into the following levels: absent, low, moderate, and high. Considering moderate and high evaluations as predictive of malignancy, the diagnostic performance of CEM was calculated using histological results of the biopsy as the gold standard. The association between LC values and the receptor profile of the neoplasms was also evaluated.


      The median age at the CEM examination was 50 years (IQR: 45-59). Considering the value of LC of the most experienced radiologist with the interpretation of Low Energy images (LE), we obtained a sensitivity (SE) of 91.9% (95% CI: 88.6%-95.2%) and a specificity (SP) of 67.2% (95% CI: 58.9%-75.5%). An association between “high” lesion conspicuity with ER/PgR not expressed (p = 0.025), with Ki-67>20% (p = 0.033), and with Grading G3 (p = 0.020) was observed.


      The new feature of enhancement, “Lesion Conspicuity”, demonstrated satisfactory performance in predicting the malignancy of lesions and significant correlation with the receptor profile of malignant breast neoplasms.

      Key Words


      CEM (Contrast Enhanced Mammography), BIRADS (Breast Imaging Reporting and Data System), LC (Lesion Conspicuity), LE (Low Energy), ACR (American College of Radiology), ER (estrogen receptor), PR (Progesterone)
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        • Giaquinto AN
        • Sung H
        • Miller KD
        • et al.
        Breast cancer statistics, 2022.
        CA Cancer J Clin. 2022;
        • Bhushan A
        • Gonsalves A
        • Menon JU.
        Current state of breast cancer diagnosis, treatment, and theranostics.
        Pharmaceutics. 2021; 13: 723
        • Ren W
        • Chen M
        • Qiao Y
        • et al.
        Global guidelines for breast cancer screening: a systematic review.
        Breast. 2022; 64: 85-99
        • Mann RM
        • Athanasiou A
        • et al.
        • European Society of Breast Imaging (EUSOBI)
        Breast cancer screening in women with extremely dense breasts recommendations of the European Society of Breast Imaging (EUSOBI).
        Eur Radiol. 2022; 32: 4036-4045
        • Veenhuizen SGA
        • de Lange SV
        • et al.
        • DENSE Trial Study Group
        Supplemental breast MRI for women with extremely dense breasts: results of the second screening round of the DENSE trial.
        Radiology. 2021;
        • Paci E
        • Broeders M
        • et al.
        • EUROSCREEN Working Group
        European breast cancer service screening outcomes: a first balance sheet of the benefits and harms.
        Cancer Epidemiol Biomarkers Prev. 2014; 23: 1159-1163
        • Freer PE.
        Mammographic breast density: impact on breast cancer risk and implications for screening.
        Radiographics. 2015; 35: 302-315
        • Sogani J
        • Mango VL
        • Keating D
        • et al.
        Contrast-enhanced mammography: past, present, and future.
        Clin Imaging. 2021; 69: 269-279
        • Cozzi A
        • Magni V
        • Zanardo M
        • et al.
        Contrast-enhanced mammography: a systematic review and meta-analysis of diagnostic performance.
        Radiology. 2022; 302: 568-581
        • Berg WA
        • Blume JD
        • Cormack JB
        • et al.
        Operator dependence of physician-performed whole-breast US: lesion detection and characterization.
        Radiology. 2006; 241: 355-365
        • Baltzer PA
        • Benndorf M
        • Dietzel M
        • et al.
        False-positive findings at contrast-enhanced breast MRI: a BI-RADS descriptor study.
        AJR Am J Roentgenol. 2010; 194: 1658-1663
        • Lee CH.
        • Phillips J
        • Sung JS
        • et al.
        ACR BI-RADS® In: ACR BI-RADS® Contrast Enhanced Mammography (CEM) (A supplement to ACR BI-RADS® mammography 2013) atlas, breast imaging reporting and data system.
        American College of Radiology, Reston, VA2022
        • Neeter LMFH
        • Raat HPJF
        • Alcantara R
        • et al.
        Contrast-enhanced mammography: what the radiologist needs to know.
        BJR Open. 2021; 320210034
        • Hoon Tan P.
        • Ellis I.
        • Allison K.
        • et al.
        The 2019 World Health Organization classification of tumours of the breast.
        Histopathology. 2020; 77: 181-185
        • Sickles EA
        • D'Orsi CJ
        • Bassett LW
        • et al.
        ACR BI-RADS Mammography.
        ACR BI-RADS Atlas, Breast Imaging Reporting and Data System. 5th Edition. American College of Radiology, Reston, VA2013: 134-136
        • Lombardi A
        • Lazzeroni R
        • Bersigotti L
        • et al.
        The proper Ki-67 cut-off in hormone responsive breast cancer: a monoinstitutional analysis with long-term follow-up.
        Breast Cancer (Dove Med Press). 2021; 13: 213-217
        • Yu KD
        • Wu J
        • Shen ZZ
        • et al.
        Hazard of breast cancer-specific mortality among women with estrogen receptor-positive breast cancer after five years from diagnosis: implication for extended endocrine therapy.
        J Clin Endocrinol Metab. 2012; 97: E2201-E2209
        • Sopik V
        • Sun P
        • Narod SA.
        The prognostic effect of estrogen receptor status differs for younger versus older breast cancer patients.
        Breast Cancer Res Treat. 2017; 165: 391-402
        • Jayasekara H
        • MacInnis RJ
        • Chamberlain JA
        • et al.
        Mortality after breast cancer as a function of time since diagnosis by estrogen receptor status and age at diagnosis.
        Int J Cancer. 2019; 145: 3207-3217
        • Ménard S
        • Fortis S
        • Castiglioni F
        • et al.
        HER2 as a prognostic factor in breast cancer.
        Oncology. 2001; 61: 67-72
        • Liedtke C
        • Mazouni C
        • Hess KR
        • et al.
        Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer.
        J Clin Oncol. 2008; 26: 1275-1281
        • Ehinger A
        • Malmström P
        • Bendahl PO
        • et al.
        South and south-east Swedish breast cancer groups. histological grade provides significant prognostic information in addition to breast cancer subtypes defined according to St Gallen 2013.
        Acta Oncol. 2017; 56: 68-74
        • Tagliafico AS
        • Bignotti B
        • Rossi F
        • et al.
        Diagnostic performance of contrast-enhanced spectral mammography: Systematic review and meta-analysis.
        Breast. 2016; 28: 13-19
        • Zhu X
        • Huang JM
        • Zhang K
        • et al.
        Diagnostic value of contrast-enhanced spectral mammography for screening breast cancer: systematic review and meta-analysis.
        Clin Breast Cancer. 2018; 18: e985-e995
        • Xiang W
        • Rao H
        • Zhou L.
        A meta-analysis of contrast-enhanced spectral mammography versus MRI in the diagnosis of breast cancer.
        Thorac Cancer. 2020; 11: 1423-1432
        • Suter MB
        • Pesapane F
        • Agazzi GM
        • et al.
        Diagnostic accuracy of contrast-enhanced spectral mammography for breast lesions: a systematic review and meta-analysis.
        Breast. 2020; 53: 8-17
      1. Nicosia L, Bozzini AC, Palma S, Montesano M, Pesapane F, Ferrari F, Dominelli V, Rotili A, Meneghetti L, Frassoni S, Bagnardi V, Sangalli C, Cassano E. A Score to Predict the Malignancy of a Breast Lesion Based on Different Contrast Enhancement Patterns in Contrast-Enhanced Spectral Mammography. Cancers (Basel). 2022 Sep 5;14(17):4337. doi: 10.3390/cancers14174337. PMID: 36077871; PMCID: PMC9455061.