Contrast-enhanced mammography in the management of breast architectural distortions and avoidance of unnecessary biopsies.

Abstract Objectives: to assess the diagnostic performance of contrast-enhanced mammography (CEM) in the management of breast architectural distortions (AD) classified as BI-RADS3 in digital breast tomosynthesis (DBT). Materials & methods: we retrospectively reviewed 328 women with 332 ADs detected on DBT from January 2017 to October 2021 and selected those classified as BI-RADS3 receiving CEM as problem solving. In CEM recombined images we evaluated the contrast enhancement (CE) of AD according to its presence/absence, type according to CEM BI-RADS lexicon, and size (<10 mm or ≥10 mm). AD with enhancement underwent breast biopsy by core needle biopsy or vacuum-assisted biopsy while AD without enhancement underwent imaging follow-up or biopsy if detected in high- or intermediate-risk women. Results: AD with enhancement were 174 (52.4%): 72 (41.4%) were malignant lesions, 102 (59.6%) false positive results: 28 (16%) B3 lesions and 74 (42.5%) benign lesions. AD without enhancement were 158 (47.6%): 26 (16.5%) were subjected to biopsy (1 malignant lesion and 25 benign lesions) while the other 132 cases were sent to imaging follow-up, still negative after two years. The sensitivity, specificity, positive (PPV) and negative predictive values (NPV) and accuracy of CEM were 98.63%, 60.62%, 41.38%, 99.37% and 68.98%. The area under the curve determined by ROC for CEM was 0.796 (95% CI, 0.749–0.844). Conclusion: CEM has shown a high sensitivity and NPV in the evaluation of BI-RADS3 AD. We showed promising results in favor of CEM as a complementary tool in assessing AD lesions to avoid unnecessary biopsies without compromising cancer detection. Clinical relevance statement: our findings are encouraging towards the utility of CEM as a valuable complementary tool for the evaluation of BI-RADS 3 AD, to reduce unnecessary biopsies for its high NPV, without compromising the effectiveness of cancer detection.