Clinical Focus Dialogue: Adventures with Contrast Enhanced Mammography

Good morning, welcome to adventures with contrast enhanced mammography. My name is Doctor Noel Berquist and I am an assistant professor at the University of Tennessee in Knoxville and today. This presentation is really aimed at those people who have not yet started with contrast enhanced mammography. I'm hoping to entice you into this wonderful world and for those of you who've already been doing it for a few weeks or a few months, or maybe even a few years just to confirm what you're doing and to give you. And new ideas, new areas to use this modality to help the work up of your patients. Disclosures, yes, Siemens did help develop this presentation. Contrast enhancement ography. What is this so? This is looking at two different features of breast tissue. First, it's looking at the difference in mass attenuation coefficient between breast tissue and iodine, and 2nd it's really looking at NEO vascularity and where have you heard that before you have heard that in breast MRI. So this is not a modality. That should be making a nervous, or you know how am I going to read this? You've seen both of these. The first of this is standard mammography, and the second of this you've seen with breast MRI, and they kind of combined the two into this new modality. Advantages of contrast. Enhanced mammography number one is accessibility. This is your breast center, your memo room, the same room that you've used for screening. Diagnostic, biopsy, tomosynthesis, and so it's very easy to move a patient over and just add this exam on during your workflow. Image acquisition takes approximately 10 minutes and how can I say that? Well in 10 minutes the contrast washes out. So you're done. The good thing about this is is generally it only takes about 6 to 8 minutes, so you will be able to get all of the images that you want done in that amount of time. Cost cost is a great benefit for this modality. It's approximately 1/4 the cost of MRI and a lot of my patients that are reluctant to pay for an MRI or very happy to pay for this. We've had no difficulties with insurance coverage companies covering this modality negative predictive value. Sometimes we underrate what a negative exam really does for us, but it does answer a lot of questions and contrast, and his mammography in the literature has been proven to have a negative predictive value between 94 and 100%. Many papers put it out between 98 and 100%. There are also fewer contraindications such as aneurysm clips, pacemakers, and claustrophobia. Drawbacks it is a modality. It's going to have drawbacks. Your first drawback is Ivy contrast, and that's mainly because we're outpatient imaging mammography centers, and we're not used to placing this, but I will assure you that there are lots of creative ways you can accomplish this, and we can discuss that in the Q&A at the end of this session, possible contrast reactions and basic patient screening for renal insufficiency. Obviously, you just want to follow your. Institutional protocols for each one of these. There are false positives, papillomas, fibroadenomas and even we've seen a good deal of stromal fibrosis can demonstrate enhancement. You can have significant background enhancement which may limit sensitivity. We've kind of proven that isn't true in MRI and as they start large clinical trials of this, I suspect they will find that contrast enhancement review probably doesn't limit it as much as we imagine it could. It may limit it in some DCIS. Biopsies can be challenging again. I don't want to dissuade you from using this modality, but sometimes you are going to have to go to MRI or you will have to biopsy based on landmarks, but we've had great success at our center and we've found that these challenges are minimal at most radiation doses. I think the easiest way to explain this is one additional 2D image so the the radiation exposure is like one additional mlo projection. OK, we're not going to get stressed out about that. Alright lesion location and this is something you just need to be aware of, but I don't think it's a really big drawback. Far medial lesions adjacent to the sternum. We all know that mammography doesn't do well there if it's not in the field of view, we're not going to see it, so just be aware if you're looking for something in that area, you need to do modified views or do a different exam. Paget's disease, it hasn't really performed well with that all right chest wall. You've already looked at that as well. On your basic mammograms. So if you know you're concerned about invasion, you're going to send them to a different modality in the axilla. But generally we've already worked up the axilla, so again, that's a limited drawback. All of these are very limited drawbacks. Contraindications these are patients that I'm not generally going to send to contrast enhanced mammography. Pregnant and lactating patients, patients with implants, and there is a caveat to that one renal failure patients. Anyone with a serious contrast reaction and someone who's too young for mammography. So those all makes sense, right? How are we using contrast enhanced mammography at the University of Tennessee? So I put these in order in the way I would like, y'all. If you're developing a program to really start your program, I always say startsmart. When we started breast MRI, we took biopsy proven cancers and we put them in the magnet. When we started contrast enhanced mammography. We took biopsy proven cancers and we put them in our machine and we did that for months. OK, so and I encourage you. For months and months and months find out what cancer looks like before you brand into the diagnostic or the screening. World response to new adamant therapy. This is a wonderful modality for that you're going to see that in some of these cases, annual high risk screening. It is really slotting in well there we do a lot of outside film ovaries because we are a tertiary referral center. It really helps us focus our workups and complicated workers. Again, it helps us sort things out. But the latter two or three of those need to be kind of later, after you've kind of developed your comfort zone with this modality. Alright, let's start with normal. When I'm training my resident, I find the one thing nobody teaches them is normal. OK, but the first thing you're going to do when you start this program is you're going to hold your breath and you're going to be. What am I going to see and then you're going to be one. Am I supposed to see? So I wanted to send give you a few cases so that you could know what is normal and what is not alright case number one. This is a heterogeneously dense breast and a patient. Here for screening we did a contrast enhanced mammogram. Now this is how I like to lay mine out, but there are many different ways and what works for you is best for you. But you can see I have my outside or my 2DS the inside or my contrast enhance mammogram. This is considered essentially no background enhancement and this is a negative exam and the first thing I want to point out to you is how fast did you read that study really fast? What 5 seconds, OK? And how accurate really accurate. OK, so that's what you're gonna love about this modality. You get your answers, it's fast and it's accurate. Alright? So this is a no background enhancement. This is a 41 year old, high risk, greener with a lifetime risk of 40% and I'm really showing you this case to show you what severe background enhancement looks like so you can see that she's extremely dense. And when we do, the contrast enhanced mammogram, she still demonstrates diffuse enhancement. This is her right breast. Again, we see the extreme density on her 2D images when we give her contrast, she enhanced markedly. Bilaterale. This is another example of severe, or this is an example of severe background enhancement. So this is my third case and this is really to illustrate moderate background enhancement, but it actually has the benefit of demonstrating two separate findings. We see extremely dense breast tissue bilaterally, and when we gave this lady of contrast enhanced mammogram, the images that are demonstrated at the top, we see that almost all the background is subtracted out. What's left is what's enhancing and this is considered moderate background enhancement. But we also see this mass in the. Right breast, which demonstrates a uniform wall enhancement, which is a little obscured along its margins, but its inner margin is very sharp and therefore when we think MRI, we know that this is going to be an inflamed cyst. Here again, we can see the inflamed cyst again. A little thickened wall, but sharp on the medial margins, and we can see another example closer up example of heterogeneous background enhancement. This is her other breast. Another great example of moderate background enhancement. We're subtracting out all of that density. Let's move into the cancer and the ways we're going to use this. The way we're going to start using this in our program number one is going to be preoperative extent of disease and contralateral surveillance. When would I choose contrast enhancement ography instead of MRI? Well, obviously the pacemakers, aneurysm clips and neurostimulators are the contraindications, so anybody that can't receive an MRI will send the contrast enhance mammography. But I would say that comorbidities. And claustrophobia are the two places that this lots and so well. I have so many patients that just cannot tolerate an MRI. Whether they have lung disease or they've had a stern otomy or they have lumbago. And this modality, if they're already looking at getting one of these two exams, they've already done a mammogram, right? And that's all you have to do. You just have to be able to do a mammogram. Closter phobia is also quite common in our area, and this lots in very well. The last of these. With gadolinium deposition disease, obviously this is just kind of touched on in the literature at this point, but we do have to start considering all these women were scanning with breast MRI's over a lifetime receiving gadolinium every year. So that's just something to keep in the back of your mind. Case number 166 year old female presents to the breast center with a history of bilateral breast pain. So you're looking at this case. This is like a mammographers dream, right? She's scattered. She's got this isolated Oval spiculated high density mass at approximately 6 to 7:00 o'clock in the poster depth of the right breast. We went ahead and we took her to ultrasound. That's this upper image alright, this is her primary mask and in her right axilla we see a deposit that's very similar with posterior shadowing to her primary. These were both biopsied and they demonstrated invasive carcinoma. We went ahead and sent her to a contrast enhanced mammography mammogram predominantly because we were just doing the modality and we wanted to see how she looked. So this is what you're going to expect to find. How fast did you read this image? OK, this was almost an instantaneous modality, right? We don't have 2000 images to go through. We have four and we get the answer right. We have an isolated side of disease on the right breast and look, we screened the left breast and we see nothing. So the patient is ready to go and see the surgeon. So this patient was being worked up after an abnormal contrast, PE embolism study and they had noticed a mass in the left breast and we can see this high density spiculated mass sitting between the 12:00 and 1:00 o'clock position. But you can probably see at the six o'clock position as well the left breast demonstrated a fine diffuse nodular pattern which was asymmetric compared to the right and therefore we decided after we saw these mammograms. The thinner daughters and we did a biopsy and then we decided to move on to contrast, enhance mammogram before surgery. So these are her contrast enhanced mammogram images and you can see our primary hydro mark which is our percutaneous clip that we use at our facility up there toward the one o'clock position and then you can see these other two enhancing masses which are in an entirely different quadrant, right? So of all the little nodules that were demonstrated on her original mammogram. Contrast enhanced mammography. Demonstrated 2 sites that should be suspicious. Here is the right breath and again I can't stress the importance of the negative predictive value of contrast enhanced mammography because, at least at our facility, we see a lot of contralateral disease and here we can see that there's no abnormal enhancement here on the left breast. We had these two small enhancing masses and they're sitting adjacent to the primary, but they're about two to two and a half centimeters away, so we went ahead and took these and we did tomosynthesis images. Here are the tomosynthesis images. So we have tomosynthesis image spot image, tomosynthesis image, spot image and we can see how well this wide angled cementoma synthesis view demonstrates these high density small spiculated masses. Our next case is going to be an 85 year old female who presented for an asymptomatic screening mammogram. She had a history of left mastectomy for breast cancer. In 1990 we had no prior mammograms on this patient, so she's the new baseline. She's heterogeneously dense, and one of my partners said, gosh, this looks suspicious. So we went to ultrasound and we can see that there is a dense shadowing mass. In the 10:00 o'clock position, 4 centimeters from the nipple, and we biopsied it. This proved to be invasive breast cancer with tubular features. Here we can see on contrast enhanced mammography. We have all this density, right. We can see our marker and we can see a residual enhancing mass. Alright, we see it up here. But wait a minute, what else did we see here down here? We have something that is enhancing. That's unlike the rest of the breast, right? We don't see it on the mlo. But why were we not surprised at that? We're not because this is in the medial aspect of the breast, and the amylose do not show that area as well as we would all like, correct? A point of this case is is one view on a contrast enhanced mammogram? Is there real finding until you prove it otherwise? Alright, so this is just to show you again this is a spot view. This is a wonderful wide angle Tomo synthesis image and you can see the spiculated little guy, but if you weren't looking for him you could walk right by this. Again, here is our spot view and here is our ultrasound. They look identical at two to three o'clock, 6 centimeters from the nipple. We biopsied it and it demonstrated invasive lobular carcinoma, so she had two cancers on opposite sides of the press and this one was found just because we did that, contrast enhanced mammogram. Here's an extra case. Then I just added this to the collection to show you that in MRI sometimes we really struggle after a biopsy with period. But few reaction and the surgeons want to know how big is this? And then the MRI. You're like man, I don't know. Anyway here you can see we've got this post biopsy hematoma and with contrast enhancement Mogra fi, we just subtract all of that out. OK, and she didn't really have much residual 'cause she had a little tiny group of calcifications, but it's subtracts all that background information out. Alright, next case monitoring new agement chemotherapy. I cannot tell you how much I enjoy using this modality for this indication, and I'm going to just show you some great cases. But first of all, let's look at this contrast enhancement. Mograph E has good correlation, and agreement with histopathology for measuring residual disease after neoadjuvant chemotherapy. It is compareable to MRI showing a high positive predictive value. And specificity for detecting residual disease in this paper and I referenced this at the end, they showed that MRI once again demonstrated a slightly increased sensitivity, but contrast enhanced mammogram demonstrates a better specificity and positive predictive value, and that's how they consider them essentially similar. This is an 81 year old female presenting for annual screening mammogram with history of left, lumpectomy for invasive lobular carcinoma in 2013 on suppression therapy for five years, who declined radiation. So we can see bilateral CC animelo projections. She is, I would call her extremely dense. She's had a lumpectomy in the upper outer quadrant of the left breast. She's actually had a percutaneous biopsy in the upper outer quadrant. Of the right breast and one of my partners thought I think she's getting a little more dense in that upper outer quadrant of the right breast. So we went ahead and took her to additional work up with Spock used an ultrasound which came back positive after she had a positive biopsy. We took her to contrast enhanced mammography. Here are her contrast enhanced mammograms in the upper half of your screen on the lower half of her 2D low energy images we can see her old surgery site on the left side and once again never disregard your negative predictive value on the right side. We can see this large enhancing mass which measured about 5 or 6 centimeters, but we see no other sites of disease on either side. Once again, the right breast. We see this very dense breast with lots of architectural distortion. We have a lobulated enhancing mass in the upper outer quadrant of the right breast with now two biopsy clips within it. And here on the left side again we have this extremely dense breast post surgical changes with absolutely no enhancement. She underwent neoadjuvant chemotherapy, and we reimaged her prior to surgery, and this is where contrast enhanced mammography really shines. OK, so this is October 2021. We first diagnosed her here. She is in February of 2021. You might say there was a little dig decreased density, but if we look at the mlo projection, and it looks like she's got a little increased density. So for the most part, not as significant change on her. Mammogram, so we went to ultrasound and I can tell you I did this study myself. She measured exactly the same. I don't quite remember the measurements, but she meant measured exactly the same between her first and her second studies. This is pre this is chemo follow-up. And so we took her to a contrast, enhance mammogram, and look at this. First off, look how easy this study was to read. OK, so we have an enhancing mass and we have nothing alright enhancing mass with nothing. So this is our biopsy clip. This is the remote biopsy clip. OK, but then what is pathology? Say right that's the gold standard and here it is. Negative for residual invasive lobular or lobular carcinoma and ciety with extensive fibrosis. So our contrast enhanced mammography mammogram. That there's nothing there, and there was nothing there, all right? And it's really hard facing these patients when they come in and your ultrasound looks identical. Explaining to them that there's probably a lot of fibrosis. You show them these two images and that just makes their day. All right, 65 year old female presenting with right sided palpable abnormality. This was one of our first case as we did with contrast enhanced mammography. She came in complaining of this mass in her right axilla, but as you can see, she's got a lot of increased density in the 12:00 o'clock position as well. We worked her up and my ultrasound technologists found the primary math and she found some lymph nodes, but she found little things everywhere. I'm talking everywhere in the breast, and so we were trying to decide where do we buy the? How do we determine extent? Of disease. And here it is. So we decided. Let's use contrast enhancement mammography and see what we find. So here's our primary math. But we see all of these satellite lesions. And here's her primary mass, and we see all of these satellite lesions, and then her adenopathy. And I can tell you one of the reasons I love working where I I do is I got to take some time and I found it proved all of these OK and we ended up buying this one and this one. And they were both cancers. And then this was adenopathy. But we're looking at neoadjuvant chemotherapy, so she underwent that, and she came back five months later. And here I'm gonna show you this as her pretreatment posttreatment pretreatment posttreatment. And you can say, how fast did I read that exam really fast? How comfortable am I with that exam? Very comfortable. You could. Actually, there's a little tiny bit of enhancement thing just adjacent to the clip. Yeah, maybe 2 millimeters. We still have some prominent nodes, but we're not. Surprised at that. OK, what did her pathology show? 4 millimeter focus of residual invasive ductal carcinoma. So we are about 2 millimeters off. Alright. How wonderful is that to have a modality that you can do quickly in the office? That's very easy to read, has a very short learning curve, and is quite accurate. All right, let's keep moving. Case number for surveillance for high risk patients and some intermediate risk. The ACR recommended in 2018 to change the recommendations. They stated that if you had a history of breast cancer in dense breast, or if you were diagnosed before the age of and this should read 50 that these patients have an increased 20% lifetime risk and they should be screened with breast MRI. However, as you and I both know, a lot of the patients in this cohort are older. They have a lot of comorbidities. And so contrast enhancement ography is a nice exam when your patients are like I don't really want to screen with an MRI, you're like, hey, I have another answer. So this is a 77 year old female with history of left breast conservation therapy in 2011 and she presented to our department for her annual screening mammogram. As you can see, she's heterogeneously dense, she has extensive distortion in the post lumpectomy bed, which is not unsurprising, but her eyebrows had a very I called amatti pattern. Does a lot of distortion throughout it, and this had not clearly changed on previous mammograms. But because of the pattern it would be. So easy to miss something. So I sat down and talked with her and she didn't want to do MRI. She had tried it years before so we did a contrast enhanced mammogram which you can see at the upper half of your screen and you can see how quickly you looked over these images. There's no significant background enhancement and there's no suspicious enhancement. Here we can see the right breast. This was the one that did not undergo therapy. She's had her Guiseley dance and you can see how the contrast enhanced mammogram just subtracts the tissue. Here is her last breath. She's had previous therapy on this side, with a lumpectomy and radiation. But once again, it subtracts all that background complexity out. And we have a negative contrast enhanced mammogram with no significant background enhancement. Let's look at this so this is an outside film over read. We are a tertiary care center and so we get a lot of referrals into our surgeons. We do outside film over reads for all of those patients just to make sure that all of the bases have been covered and they're ready for surgery. We have found this modality to be an ideal modality for evaluating some of these patients as they come in, because we do them as a full same day workout. So let's look at this case. This is a 33 year old female and she presented to an outside facility twice over several months with complaints of fullness and a palpable mass with burning in the left breast. Now I will explain that this patient had had a previous breast reduction. OK, her workups were performed six weeks apart and both of them read unremarkable. After the first work up, she was placed on antibiotics and I completely I. I think they did the right thing. So after the second return they decided to send her. The MRI, so the reports read changes in keeping with reduction surgery. MRI was recommended. She decided to come seek a second opinion at our facility. So here are her original workout mammograms and you can see she's super heterogeneously dense. These are her Tomo synthesis images and there's just all this architectural distortion out here. This is the upper outer quadrant of the left breast, maybe some distortion over here but mainly this just you could see it from across the room and you start getting nervous right? So we decided to send her to a contrast enhanced mammogram because she's just so difficult, right? So here you have your four images, and you've quickly seen there's some moderate background enhancement of the right breast and a window painting distribution, but you don't see anything suspicious, so let's go to the left breast. You know it's really interesting, and I'm going to go ahead and move us forward. Here is our contrast. Enhance mammogram. Here's our low energy. What you would consider a 2D image. And here's our tomosynthesis image, and you can see this is where your eye is, just like Oh my goodness, this looks awful, right? And on our low energy images, it doesn't really help us. We don't see calcifications, and this doesn't change, but when we moved back to the contrast, enhance mammogram. This is the area that's nonenhancing right? This area over here with all the fat is what's enhancing right? So this really completely teaser workout focus for this patient because her reduction changes which are pretty exaggerated and uncommon were distracting from what was really going on over here. So we got to redirect our work up. And we went to ultrasound. So here we can see, I think there was a 78 centimeter spance of disease and here she had a little thickened lymph node. She was sent to breast MRI. She is 33 so some of these patients will still go to MRI, especially if you're using contrast enhanced mammography. During your diagnostic work up. So we wanted to scan both breasts and I really set this up because I've oriented these in the same manner. Here is her enhancing tumor here is her enhancing tumor, and here is her enhancing tumor, so they all agree. The caveat to this is her right breast agreed as well, so this is her MRI of the right breast. She just had background enhancement. Here is her, her contrast, enhanced mammogram, and she just has some moderate background enhancement. So this is your nice negative predictive value. So this is a 70 year old female with multiple bilateral breast masses by mammography, ultrasound and MRI. Here are her bilateral CC animelo projections which demonstrate heterogeneously dense breast parenchyma and multiple bilateral masses of various sizes. Here are her tomosynthesis views. Again, you can see they're just multiple bilateral masses now. This was an outside study series and she had already had these called up for biopsy. Two places on the right and three places on the left. Here is her left breast. You can see even more circumscribed Oval and round masses scattered throughout the heterogeneously dense background. We sent this person to contrast enhanced mammogram because she had an outside facility MRI and it's very difficult to get a second MRI. It did not work with our MRI software package and so we chose a contrast enhanced mammogram to try and direct our work up. And as you can see there is scattered nodular enhancement bilaterally. Not surprising we would call this moderate background enhancement but in the lower inner quadrant of the left breast. There is an irregular. Asymmetry or enhancing focal asymmetric density? You would probably call this non mass enhancement. Here on the right breast again you can just see some mild background nodular enhancement. Nothing unique on the left breast here. Once again we see this non mass enhancement in the lower inner quadrant. It's band 18 millimeters and it was unique, so that's what we're looking for right? What's unique. Here's her outside facility, MRI on the left of your screen, and here's her contrast, enhance mammogram on the right, and again she came from an outside facility they had called at least two things on the right and three things on the left, and so we did. The contrast enhanced mammogram to try and sort these out. And as you can see, although there's lots of background enhancement that is confusing on the MRI, there's really not a lot suspicious on the contrast, enhance mammogram, and so we focused our attention to this lower inner quadrant area of non math enhancement. Summary This is really easy to add to your workflow. There is rapid. There is a rapid learning curve for both physicians and technologists. I will say if you're already doing mammography and you know something about MRI, you're already there. OK, anytime you have a question with this modality, you just put your MRI hat on and you think what would I do or what would this look like? You've already got your answer for the technologist. I spoke to them independently and it took four hours. Of training and they say they feel very comfortable with this modality. Patients tolerate this very well. I will have to say I have a lot of patients that literally tell me I don't ever want to go into MRI magnet again. This is a wonderful mentality, especially for high risk population. The ladies who've already had breast cancer and are dense. And they're older. You know they're in their 60s, seventies, 80s. This is a wonderful modality because if they can do a mammogram, they can do a contrast enhanced mammogram. Good sensitivity and specificity as well as negative predictive value, and that's been proven time and time again. It's similar to breast MRI. Alright start smart. Start how you did with MRI with your vibes, you proven cancers and don't rush ahead and give yourself a marked out six months if not longer because there are some your brain just kind of has to learn how to look at these images. After you do, you just start really enjoying them. But you do just really need to kind of. Hold back on the reins before you jump into the screening world or the diagnostic world for at least six months. Limitation OK again, no axillary evaluation, but generally you've already looked at that with ultrasound. You can't see your chest wall, but again, you can already tell if there's that behind the mask on your mammogram, and so that's there. And then of course, your immediately things you want to be careful about that. Alright, these are my references and I really wanted to point out if you're just getting started this number three. It's called contrast enhanced mammography. State of the art published in radiology in 2021. This is a really nice article to just kind of review, refresh, or just start looking into this modality. I think you'll really find it helps you out a lot. Well, I really appreciate you joining us today and I hope that you enjoy contrast, enhance mammography as much as I do.

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Hilal, M. Covington et al., "Contrast-enhanced spectral GRADE abnormality. There are False Positives: , Papilloma, Fibroadenoma, Stromal fibrosis Dense Breasts. AJRAm J Roentgenol 2018;211 Response Mammography mammography, ultrasound, and MRI. between breast tissue and iodine on HRT for 5 years, declined XRT Mammography. central left is Normal on In this paper they showed that MRI once again What is Normal? at is No€nal? NPV is high 94 - mammography is comparable to MRI in the assessment of residual breast cancer Work ups were performed 6 weeks apart, both Seimens Inc. Claustrophobia OSFOR's (we are a referral hospital) biopsy proven cancers effect with biopsy site changes.' Siemens Inc., Honoraria directed to UT Breast Center. 1990 CHEMO F/U and Dense breast tissue Disease and Chemotherapy Response following neoadjuvant systemic therapy," Annals of Surgical Oncology, vol. 25, You can have significant Background Enhancement, limiting Sensitivity Serious Contrast Reaction. 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MRI Contralateral Claustrophobia and claustrophobia Right Axilla some intermediate risk. 4. siemens-healthineers mammographie mammomat- (These groups have a >20% lifetime risk) Radiation Doses: 1.2 - 1.5 FFDM (similar to tomosynthesis) assessment, but you've generally already looked risk screeners) Noél M. Bergquist, M.D. 7. V. lotti, S. Ravaioli, R. Vacondio et al., "Contrast-enhanced spectral was recommended. Mastectomy: 4mm relevation TICEM Whitepaper 1800000006867615.pdf (scrvt.com) ppv. principle as MRI with neovascularity and "leaky" mammography in neoadjuvant chemotherapy monitoring: a comparison with with US, so you can weed those patients out if RT BREAST 6 cm fn Assistant Professor LONG Lesion Location: far medial, Paget's, chest wall, axilla 3.0 2.0 Surveillance breast magnetic resonance imaging," Breast Cancer Research, vol. 19, no. 1, Rcc and Rcc subtraction tumor vascularity. (4) focus of resi need be. IDC. She sought a second opinion at our facility. 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