November 27, C.Bour MD
Angiomammography is a recent technology that is not useful for screening but in diagnosing lesions and for particular indications.
We're talking about it because it's a technique you've probably heard of, and the French Health Authority recently examined it.
What is angiomammography?
This procedure combines mammography with the injection of a contrast agent to analyze contrasting lesions. It is possible to differentiate benign from malignant tumors based on the tumor's vascular behavior, specifically the emergence and subsequent fading of the vascular enhancement.
After injecting the contrast agent into the patient, mammography is conducted with two incidences (one frontal and one oblique per breast) in two acquisitions, one low and one high energy, as is usual.
The glandular tissue and fat can be separated by recombining the images produced with these two acquisitions, leaving just the contrast of the lesions of interest apparent on the recombined images.
The end result is a type of mapping that allows for visualizing highly vascularized lesions such as cancers.
However, the dose delivered to the gland is higher due to the repetition of the acquisitions, once at low and once at high energy. The additional irradiation is approximately 1.2 times the usual dose for each image.
Why no indication in screening for women at high risk of breast cancer?
This technology is more irradiating than conventional mammography; MRI appears to be more suited because we usually want to limit irradiation in this at-risk population, for whom ionizing radiation is a potential factor in cancer induction.
What is the advantage of this technique compared to MRI?
It is quick to perform. Because the same incidences are used, it is simple to analyze the images and compare them to earlier mammograms (faces, obliques).
It is, however, irradiating and is not recommended for women who are at high risk of cancer. There is always the potential of allergy to the injected contrast products, even if it is low.
HAS (French Health Authority) recommendations
Angiomammography could be used in the following situations:
- diagnostic impasses, to confirm the presence of a suspicious lesion or to rule out the presence of a lesion, although with necessary follow-up;
- when contrast imaging is required:
- locoregional extension assessment (tumor size and search for additional lesions);
- evaluation of response to neoadjuvant chemotherapy;
- tumor evaluation before neoadjuvant chemotherapy, but experts noted that breast MRI is currently the reference examination in this indication.
Two situations to be considered:
Angiomammography is recommended in the following situations where MRI is contraindicated:
- diagnostic impasses;
- locoregional extension assessment of cancer;
- tumor evaluation before and after neoadjuvant chemotherapy.
In the absence of contraindications to MRI, angiomammography is recommended
- In assessing locoregional extension or before/after neoadjuvant chemotherapy, for evaluating the tumor size, particularly for its perfect correspondence with the mammography images.
According to HAS, a quality control policy should be implemented to ensure optimal doses are always used and that the facilities are monitored.
More robust performance studies and meta-analyses are needed to confirm the diagnostic efficacy of angiomammography.
The HAS recommends conducting clinical research studies to confirm diagnostic performance data, to demonstrate the clinical usefulness of angiomammography, define its role in the diagnostic strategy, and determine its impact on therapeutic management (number of biopsies, the relevance of the surgical decision, rate of reinterventions, etc.).