Contrast-enhanced mammography for breast cancer detection and diagnosis with high concentration iodinated contrast medium

Objectives: We assessed the diagnostic performance of contrast-enhanced mammography (CEM) using a high-concentration iodinated contrast medium (HCCM, 400 mgI/mL) to determine whether the reduced iodine dose and increased iodine delivery rate (IDR) achieved might offer a more sustainable alternative to CEM performed with lower iodine concentrations. Methods: This two-center retrospective study included 205 patients who underwent CEM between March 2021 and February 2022. Patients were injected with HCCM at 1.0 mL/kg bodyweight at an IDR of 1.2 gL/s. Standard cranio-caudal and mediolateral-oblique views were acquired. Images were reviewed independently by two experienced radiologists who were blinded to patient clinical and imaging information. Diagnostic performance, including sensitivity, specificity, and accuracy, was assessed based on histological or long-term imaging follow-up as the reference standard. Results: Among the 205 patients, 149 (72.7%) had malignant lesions, and 56 (27.3%) had benign findings. The sensitivity and specificity of CEM were 96–97% and 84–87.5%, respectively, with an overall accuracy of 93–95%. The IDR achieved with HCCM resulted in excellent contrast enhancement, particularly in patients with aggressive malignancies. ROC analysis confirmed the good diagnostic performance, with AUC values of 0.90–0.92. Compared to conventional mammography and ultrasound, CEM demonstrated significantly higher diagnostic accuracy, especially in patients with dense breast tissue. Conclusions: CEM with HCCM provides excellent diagnostic performance, achieving high sensitivity and specificity while allowing for a reduced iodine dose and increased IDR. This approach may offer a more sustainable alternative to conventional contrast media without compromising diagnostic accuracy, particularly for the detection and characterization of aggressive breast lesions. Critical relevance statement: This study demonstrates that reducing the volume of injected contrast media while increasing iodine concentration maintains the diagnostic benefits of CEM, further supporting its potential to improve early cancer detection, thereby advancing clinical radiology practices and optimizing screening strategies for women with dense breasts. Key Points: Currently, CEM protocols utilize a variety of iodine concentrations and flow rates. CEM with high-concentration contrast (400 mgI/mL) achieved 96% sensitivity and 87.5% specificity. High-concentration contrast in CEM improves early detection of aggressive breast cancers.