title: Staging of breast cancer and the advanced applications of digital mammogram: what the physician needs to know?
abstract: OBJECTIVE
  To study the role of advanced applications of digital mammogram, whether contrast-enhanced spectral mammography (CESM) or digital breast tomosynthesis (DBT), in the "T" staging of histologically proven breast cancer before planning for treatment management.
  
  
  METHODS
  In this prospective analysis, we evaluated 98 proved malignant breast masses regarding their size, multiplicity and the presence of associated clusters of microcalcifications. Evaluation methods included digital mammography (DM), 3D tomosynthesis and CESM. Traditional DM was first performed then in a period of 10-14-day interval; breast tomosynthesis and contrast-based mammography were performed for the involved breast only. Views at tomosynthesis were acquired in a "step-and-shoot" tube motion mode to produce multiple (11-15), low-dose images and in contrast-enhanced study, low-energy (22-33 kVp) and high-energy (44-49 kVp) exposures were taken after the i.v. injection of the contrast agent. Operative data were the gold standard reference.
  
  
  RESULTS
  Breast tomosynthesis showed the highest accuracy in size assessment (n = 69, 70.4%) than contrast-enhanced (n = 49, 50%) and regular mammography (n = 59, 60.2%). Contrast-enhanced mammography presented the least performance in assessing calcifications, yet it was most sensitive in the detection of multiplicity (92.3%), followed by tomosynthesis (77%) and regular mammography (53.8%). The combined analysis of the three modalities provided an accuracy of 74% in the "T" staging of breast cancer.
  
  
  CONCLUSIONS
  The combined application of tomosynthesis and contrast-enhanced digital mammogram enhanced the performance of the traditional DM and presented an informative method in the staging of breast cancer. Advances in knowledge: Staging and management planning of breast cancer can divert according to tumour size, multiplicity and the presence of microcalcifications. DBT shows sharp outlines of the tumour with no overlap tissue and spots microcalcifications. Contrast-enhanced spectral mammogram shows the extent of abnormal contrast uptake and detects multiplicity. Integrated analysis provides optimal findings for proper "T" staging of breast cancer.
authors.affiliation: 1 Women's Imaging Unit, Department of Radiology, National Cancer Institute, Cairo University, Egypt.
authors.forename: Maha H
authors.initials: MH
authors.lastname: Helal
authors.affiliation: 2 Women's Imaging Unit, Department of Radiology, Kasr El Ainy Hospital, Cairo University, Egypt.
authors.forename: Sahar M
authors.initials: SM
authors.lastname: Mansour
authors.affiliation: 1 Women's Imaging Unit, Department of Radiology, National Cancer Institute, Cairo University, Egypt.
authors.forename: Mai
authors.initials: M
authors.lastname: Zaglol
authors.affiliation: 2 Women's Imaging Unit, Department of Radiology, Kasr El Ainy Hospital, Cairo University, Egypt.
authors.forename: Lamia A
authors.initials: LA
authors.lastname: Salaleldin
authors.affiliation: 1 Women's Imaging Unit, Department of Radiology, National Cancer Institute, Cairo University, Egypt.
authors.forename: Omniya M
authors.initials: OM
authors.lastname: Nada
authors.affiliation: 1 Women's Imaging Unit, Department of Radiology, National Cancer Institute, Cairo University, Egypt.
authors.forename: Marwa A
authors.initials: MA
authors.lastname: Haggag
mesh_terms: D000328:Adult; D000368:Aged; D001940:Breast / Q000000981:diagnostic imaging; D001943:Breast Neoplasms / Q000000981:diagnostic imaging* / Q000473:pathology*; D003287:Contrast Media; D005260:Female; D006801:Humans; D008327:Mammography / Q000379:methods*; D008875:Middle Aged; D009367:Neoplasm Staging; D011446:Prospective Studies; D012372:ROC Curve; D011856:Radiographic Image Enhancement / Q000379:methods*; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity
chemical_list: D003287:Contrast Media