Combined Contrast Enhanced Mammography and Digital Breast Tomosynthesis in Patients Suspected of Having Breast Cancer: A Prospective Comparison With Digital Mammography and Breast MRI —Findings of the CONTEST Study

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INTRODUCTION: We aimed to assess diagnostic performance and accuracy for local staging of CEM combined with DBT (CE + DBT) compared to digital mammography (DM) and MRI. METHODS: Female patients aged 18-70 years with clinical or sonographic suspicion of breast cancer had CE + DBT and breast MRI prior to treatment. Diagnostic accuracy, ability to identify additional disease foci, and disease extent estimations were compared for all imaging techniques. Histopathology was the reference standard. RESULTS: Eighty-seven participants were recruited; 80 included in the study; 69 had cancer. DBT had greater diagnostic sensitivity than DM, but lowest specificity. CEM and CE + DBT showed 100% sensitivity. Specificity was lower for CE + DBT than CEM alone. MRI sensitivity was higher than DM or DBT, but lower than CEM or CE + DBT. MRI specificity was lower than CE-DBT, both separately and in combination. Thirty-nine patients were included in exploratory subset analysis regarding identifying additional foci. DM missed the most cases (8/10); DBT had higher sensitivity but lower specificity; MRI s sensitivity but with more false positives; CEM had the greatest overall accuracy. Thirty patients were included in unifocal disease extent analysis. MRI, CEM, and CE-DBT all demonstrated strong correlation with pathological size, with MRI showing closest agreement. CONCLUSIONS: Combined CE + DBT is feasible within a one-stop clinic appointment and may obviate the need for MRI. CEM demonstrated comparable accuracy to MRI, both for diagnostic accuracy and in local staging. We showed no clear benefit to combining morphological information derived from DBT with functional data of CEM compared to CEM alone.

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