Author: Gamze Durhan, MD¹,
Affiliation: ¹ Department of Radiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
Dear Editor in Chief,
I read with great interest the educational review article entitled “High-risk lesions of the breast: concurrent diagnostic tools and management recommendations” authored by Catanzariti et al.  in the June 2021 issue of Insights into Imaging. The authors comprehensively presented the radiological aspects, information about potential upgrade rates, and clinical management of high-risk breast lesions. This is a very useful and educational article as high-risk breast lesions are commonly seen in our daily practice and their management is controversial. In addition to conventional methods including mammography and ultrasonography, I think contrast-enhanced mammography (CEM) can be very useful for the assessment of high-risk breast lesions. I would like to point out the imaging findings of high-risk breast lesions on CEM and the potential benefits of CEM.
CEM is an emerging diagnostic tool that uses iodinated contrast agents to detect breast neovascularity similar to breast MRI . High-risk breast lesions including atypical ductal hyperplasia, lobular carcinoma in situ, atypical lobular hyperplasia, flat epithelial atypia, radial scars, and papillary lesions show contrast enhancement due to their proliferative and vascular nature [3, 4]. However, there aren’t any morphological and kinetic MRI features that are specific for high-risk breast lesions [1, 4]. Although high-risk breast lesions without microcalcifications cannot be detected on digital mammography images especially in patients with dense breasts, CEM can demonstrate high-risk breast lesions with mass or non-mass contrast enhancement (Fig. 1). Parenchymal distortions which are characteristic of a radial scar can be vague in patients with dense breasts. CEM improves lesion conspicuity and makes parenchymal distortions more visible. On the other hand, low-energy images of CEM which replace digital mammography images with similar performance show microcalcifications that can be seen in lobular neoplasia, atypical ductal hyperplasia, and flat epithelial atypia. Contrast enhancement in the area of microcalcifications on CEM makes microcalcifications more suspicious and facilitates the radiological diagnosis of high-risk breast lesions (Fig. 1). In addition, contrast-enhanced mammography is less expensive and easier to perform in daily clinical practice compared to MRI. CEM can be used in patients who cannot undergo MRI examinations because of claustrophobia, MRI-incompatible devices, and high body weight.
In conclusion, besides digital mammography, ultrasonography, and MRI, CEM helps in the diagnosis of high-risk breast lesions by showing both microcalcifications and contrast enhancement of lesions. Contrast-enhanced mammography-guided biopsy as a very new technology may also be useful for both the management of microcalcifications and high-risk breast lesions.
Figure 1. Examples of high-risk breast lesions which are histopathologically proven in different patients.
 Catanzariti F, Avendano D, Cicero G et al (2021) High-risk lesions of the breast: concurrent diagnostic tools and management recommendations. Insights Imaging 12:63
 Jochelson MS, Lobbes MBI (2021) Contrast-enhanced Mammography: State of the Art. Radiology 299:36-48
 Durhan G (2021) Contrast-Enhanced Spectral Mammography: An Alternative Modality for Evaluation of Nipple Discharge. AJR Am J Roentgenol. 10.2214/AJR.21.25699:W1
 Heller SL, Moy L (2012) Imaging features and management of high-risk lesions on contrast-enhanced dynamic breast MRI. AJR Am J Roentgenol 198:249-255