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Contrast-Enhanced Mammography (CEM / CESM)

Mammo+ ContrastBreast

Indications

Diagnostic problem-solving and lesion characterization (alternative to MRI)
Extent of disease / local staging in newly diagnosed cancer
Supplemental screening in dense breasts or intermediate-risk women when MRI is unavailable/contraindicated
Neoadjuvant treatment response monitoring

Patient prep

Screen renal function (eGFR) and iodinated-contrast allergy history
No deodorant/powder/lotion as for standard mammography
IV access placed; verify no contraindication to iodinated contrast

Contrast

AgentNon-ionic low-osmolar iodinated contrast (iodine 300-370 mg/mL)

RouteIV (power injector)

Dose~1.5 mL/kg (max ~150 mL) at ~3 mL/s

TimingBegin imaging ~2 min after injection; acquire all views within ~2-10 min post-injection

Technique

Dual-energy acquisition at each position: low-energy (28-33 kVp, FFDM-equivalent) and high-energy (45-49 kVp, above iodine K-edge, Cu filtration)
Standard four projections: CC and MLO of each breast (affected breast often imaged first)
Recombined (subtracted) images highlight areas of contrast uptake/neovascularity, analogous to MRI subtraction
Spot/magnification CEM views can be added as needed

Series / Sequences

#	Series / Sequence	Plane	Notes
1	Low-energy CC/MLO bilateral	CC / MLO	Equivalent to standard 2D mammogram
2	High-energy CC/MLO bilateral	CC / MLO	Above iodine K-edge; used for recombination
3	Recombined CC/MLO	CC / MLO	Iodine/enhancement map; assess lesion enhancement

Key points

Low-energy images are interpreted like a conventional 2D mammogram (density/BI-RADS); recombined images show enhancement
Sensitivity approaches MRI for invasive cancer with faster/cheaper workflow; lower cost and more accessible
Image affected breast last is sometimes used to maximize enhancement window; follow vendor protocol
Use CEM-adapted BI-RADS descriptors; correlate enhancement with mammographic finding before biopsy

References

• ACR Practice Parameter for the Performance of Contrast-Enhanced Mammography (CEM)
• SBI White Paper: Contrast-Enhanced Digital Mammography
• ACR BI-RADS (CEM supplement / lexicon)
• RadioGraphics: Contrast-enhanced mammography state of the art; Radiopaedia: Contrast-enhanced mammography

Source: Researched — verify against your institution

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Reference template — verify and adapt to your scanner, vendor and institution before clinical use. Not a substitute for clinical judgment.