Contrast-enhanced mammography (CEM) can help to accurately downgrade BI-RADS 4 breast lesions. That's the key finding of a new study published on 23 August in the European Journal of Radiology.
A team led by Dr. Anna Grażyńska from the Medical University of Silesia in Katowice, Poland, reported that CEM had high negative predictive value (NPV) when it came to assessing both mass and nonmass lesions and that its use led to avoiding about 60% of unnecessary core needle biopsies.
"The use of CEM may significantly minimize the number of invasive procedures such as core needle biopsy and thus reduce diagnostic costs and improve patient comfort," Grażyńska and colleagues wrote.
CEM helps show the development of new blood vessels from a pre-existing vasculature that are linked to breast malignancies. This modality also provides morphological information on the lesions, as standard mammography does, and allows areas and lesions to be visualized that show the uptake of contrast media.
Overlapping features of benign and malignant lesions make it challenging to differentiate between the two in low-energy CEM images. This leads to a BI-RADS 4 categorization, meaning core needle biopsy is recommended for further analysis. Current guidelines for CEM in this area are "indecisive," the researchers noted.
Grażyńska and co-authors sought to analyze breast lesions classified into the BI-RADS 4 category, as well as find out whether and which lesions that are not enhanced on recombinant CEM images could be downgraded. They included data from 528 women who underwent a core needle biopsy performed between 2017 and 2022 due to a breast lesion classified as BI-RADS 4 on CEM.
The researchers found that the NPV for the entire cohort was 93.9%. They also found NPVs for the following: mass lesions, 100%; nonmass lesions, 97.8%; and microcalcifications, 87.9%.
The team reported that 230 out of 383 benign lesions included in the study were not contrast-enhancing, indicating that 60.1% of unnecessary core needle biopsies would have been correctly avoided.
Finally, the researchers found that CEM sensitivity was lower for lesions less than 20 mm (86.6%) than for lesions 20 mm or larger (94.6%).
The study authors suggested that based on their results, CEM shows high sensitivity in detecting malignant lesions with mass and nonmass morphologies.
"The high NPV for recombinant images suggests that in the case of mass and non-mass lesions, the absence of enhancement indicates the benign nature of the lesion and may lead to a reduction of the BI-RADS 4 to BI-RADS 3 category," the authors wrote.
The study can be found in its entirety here.
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&fit=crop&h=100&q=70&w=100)
![Examples of ultrasound findings and techniques. (A) Images in a 39-year-old male patient with a mass in the left thigh. The mass is heterogeneous on the B-mode US image (compared with the patient in D) and showed increased microvascularity (superb microvascular imaging [SMI]) and shear-wave elastography (SWE) values. Undifferentiated pleomorphic sarcoma was diagnosed at biopsy (with pleomorphic rhabdomyosarcoma in surgical specimen). (B) Images in an 18-year-old male patient with a mass in the left leg. The mass is hypoechoic on the B-mode image, with no other findings suggestive of malignancy. The lesion is in contact with the cortex of the tibia, which is slightly irregular. CT revealed a doubtful anteromedial tibial erosion. The microvascular study demonstrated high vascularization, suggestive of malignancy. Periosteal Ewing sarcoma was diagnosed with both histologic and immunohistochemical confirmation. (C) Images in a 69-year-old female patient with a lump growing on the outside of the left leg. Multiple SWE examinations were performed (please note the high values obtained in the measurements, whereas the color map highlights the stiffness relative to adjacent tissues). SMI showed areas of increased vascularization to target for sampling. Undifferentiated spindle cell sarcoma was diagnosed at biopsy, with residual leiomyosarcoma in the surgical specimen after neoadjuvant therapy. (D) Images in a 56-year-old female patient with a mass in the right thigh. The mass is heterogeneous at both B-mode ultrasound (similar to patient A) and MRI (coronal T2-weighted spectral attenuated inversion recovery [SPAIR]; T1-weighted pre-contrast and postcontrast imaging), which even shows uptake after the administration of paramagnetic contrast material, which is traditionally suggestive of malignancy. Low values at SMI and elastography are suggestive of benignity. Spindle cell lipoma was diagnosed at biopsy, with atypical spindle cell lipomatous tumor in the surgical specimen.](https://img.auntminnieeurope.com/mindful/smg/workspaces/default/uploads/2026/08/images-radiol250278fig2.APCFLSvX6p.jpg?auto=format%2Ccompress&dpr=2&fit=crop&h=167&q=70&w=250)
