RSNA 2025 Dr Sabine Ohlmeyer, University Hospital Erlangen, Germany: The role of contrast enhanced mammography (CEM) in personalized Breast diagnostics

So we go to our first case, case number one, please open case number one. We have a 60 year old woman. She has no complaints and she had a screening mammogram. So just look at the mammogram. It's a little warming case, warm up case. I think it's not too complicated. So I think what catches our attention is that here what we perform next is an ultrasound. We found this hyperechoic mass with the posterior shadowing here, irregular margins at the 2O clock position. And in the diagnostic work up, we performed the Tyson next as you can see here, please open the Tyson as well. And we found this mass here and we see the segmental faint enhancement in front of the mass. We have nearly no BPE on both sides, if you compare it left breast and right breast. And what I want to show you is here the new software version. We have here the clear SIM in the middle. You have it also on your workstation. You can toggle these images. And what we see here is that we have pronounced enhancement of the tumor. And the small enhancement here is easier to recognise in this case because the background is more homogeneous and it's easier to differentiate the enhancement from the background. And this is really nice here to see. We have also the, this is the CC view and the MLU. The other view is on your workstation and also prepared the MRI for you because in this case we have both because she participated in a study, we see the enhancement here and also the small enhancement in front of the tumour and here provided for you a comparison. Of course, the position is not exactly the same because we have the free hanging breast here in the MRI and this is a compressed breast. But here we see that the accuracy is similar of our diagnostic impression, the tumour here and the fatal enhancement in front of the bigger lesion. This is the preoperative marking. The multidisciplinary node decided that she could have bigger resection of segmental. The segment should be bigger here. And this is what we tried to show our surgeons with the circle here. And this is the specimen from surgery and it turned out to be an invasive lobular carcinoma grade 2. So we go to the next case, case number two, please close. Case number one, we have a 73 year old woman and she has a screening mammogram and had a break of five years between their mammograms. The upper row is from 20/20 and this row from 2025, I think it's again quite easy. There's a big mass grown over five years. We performed an ultrasound, This is the ultrasound of the left breast and on the right side we found the small hyperechoic lesions here there another one and so we decided to do a tie them again. So please look at the tie SIM. What do you think? Is everything OK in the right breast? Anything bothering you? Here we again have the newer software here the nipple, this is something in the skin and the enhancement of the tumor. Here again nearly no background in this case CC view and this is the right breast and we see. What we have found in the ultrasound CCU, we decided to biopsy both. Of course the bigger lesion is cancer. It was an invasive Dr. 'cause Noma Grade 1 hormone receptor positive and associated with low grade DCIS and his solid report of the right side said it's benign. They found some micro calcification, but they told us that's benign. For us, it was a discrepancy between the solid report in our findings and so the multidistory report decided that she should have some. Some more of what we have found left breast mastectomy and then the right side, it turned out to be an invasive tubular carcinoma invasive and desires and it was had no free. The matches have not been free of disease and so she had to undergo another surgery followed by mastectomy and there was some big desires in the specimen. If there are no questions, we go to case number three. close case number two please. And open case number three, we have a 49 year old woman. Here family. I think everyone in the room found perhaps what we found suspicious. This is what we found in the ultrasound. And she already had a biopsy in the in an external hospital, and they said it's too less tissue and it should be benign, but we didn't believe that. In this case, we have Tomo, it's also a new workstation and we performed a Tyson as well. We found some micro classifications. They are really nicely depict here and the architectural distortion was the mass and we also see the clip from the biopsy before and what you can see in the Tyson is that maybe they have to have been a little bit too craniolateral from the tumor. Maybe we decided to do a vacuum biopsy in this case to have more tissue. This is how we do all the biopsy now long in we can biopsy with the vertical arm or the lateral arm from lateral MLO or ML in this case of course with the vertical arm from from lateral approach. This is the target in here and this is the pre and post fire images and the specimen and it turned out to be an as an invasive lover carcinoma grade one with TCIS preoperative marking and then the specimen here. OK, then let's proceed. Proceed to case number four. close case number three. We have a 71 year old woman and she felt a path of a mass behind her nipple and she has no history of breast cancer. The point is already there, so the mass is really easy to find. Did you find anything else? I think that's clear. Is it the only mass or anything else? Pardon. Yeah. Anterior small. You mean that perhaps? Yeah, then some kegs here, third position and perhaps there's also something there. We have the Tyson here, it's also in the workstation, older new software, both should be there. And what we see is again the mass enhancing there, the small satellite in front of us front of the bigger lesion and then maybe some enhancement there where the calcs are maybe in this position. But the third thing here not it's not so enhancing. So this is the biopsy of the bigger lesion. Of course, it was an invasive Dr. carcinoma grade 3, and the board decided that we should go for the kegs because it was quite far away. We formed a tomo biopsy and it turned out to be benign mastopazi. Those biopsies and the multidisciplinary board decided that she should have neo adequate chemotherapy followed by breast conserving therapy and radiotherapy. And then we go to the next case. Case number 5. Please close. Case number 4, we have a 52 year old woman and the gynecologist found a suspicious mass in the ultrasound in the routine check up and she was sent to us. We found that not so suspicious. This is some complex cyst or since yesterday assist with solid and cystic parts as we learned in the new virus version. As it was rated as far it's four and we found that very unsuspicious. We performed a Tyson that we can say it's far it's 2. But on the other side, is everything OK or is anything bothering you in the right breast? There's no enhancement here in the Tyson. Some BP perhaps like in the other side. Yeah, these Cags here, we did the Max here, We decided to biopsy the CAGS and it turned out to be what you said, sclerosing adenosus. Yeah. OK. Then we go to the next case, case number six. We have a 43 year old woman and she had breast cancer in her family and she felt that she has a papal mass in her left breast and also a lymph node in her axilla, some pain in the axilla. This is the ultrasound from the mass. And this is the mammogram. What do you think? Quite dense the breast. Yeah, correct. We decided to perform a Tyson in this case because the breast is quite dense and of course we have these tumor here and the suspicious lymph node there. But we had also a lot of enhancement there here and also in the CC view. And what we do then in this case is that we compare both sides and we found also some BP on the right side. But something catched our attention, maybe yours as well, especially here in the CC view and here in the MLO, we go back to the normal mammogram. I think it's not easy to see because she has such a dense tissue. And here for comparison, the newer version we have again a lot of PPE and it makes it quite difficult in this case. But we know that already from also from MRI that it can be difficult if you have a lot of PPE in the patients. But especially here in the CC view, I don't think that you would have missed that because it's more round than the rest of the tissue. In this case, we have also an MRI. There's less enhancement, less BP in this case. But remember the patient's 43 and it was a little bit better in her menstrual cycle. So we have less BP in this case here. What we do also is diffusion weighted images. We have really high B values from 1500 and what we do sometimes is that we inverted the maximum intensity protection and we have again here the bigger lesion and the satellite here or the probably satellite what we suspect. Then we went back to the ultrasound, 2 two and the targeted ultrasound, if you can find it there. This is the small lesion here. Perhaps an alternative would have been to do a symbiopsy. If you have it, then you can be more sure because it's yeah, for sure the same here. You have to guess a little bit if it's the same. We placed the clip and checked it afterwards that we have been in the right position and it was the same tumour type also in invasive ductal carcinoma grade 3. In this case there's another MRI here because as I told you, she participated also in a study. She get vaccinated with a orange tumour and is completely but still she has to undergo mastectomy because the lesions have been quite far away from each other. OK, then close case number six. We go to case number seven. We have a 56 year old woman. She has already known kegs in the right breast since the age of 40. A look at the mammal, we found it a little bit more pronounced compared to the priors here we decided to do a Tyson and the diagnostic work up. We have a faint little enhancement there and this is the Tomo suspicious calcification on slice 27 and even not so easy to see in the mammogram here, it's really easy to find because it's a little bit more pronounced here in the Tomo. And then this is the specimen from the Tomo biopsy and it turned out to be Adesia is high grade which correlated with the non mass enhancement which we have seen in the Tyson. OK, we go to case number 8. We have a 69 year old woman and she already had breast cancer and the right breast in 2020. She already had New Advent chemotherapy and breast conserving therapy and radiotherapy, and we look at her annual follow up after breast cancer. And what do you think, is it OK or not what you have rated as far it's two maybe we've not been pretty sure what is in front of the clips here. Is it more dense as in the year before? Is it just a scar or is it a recurrence of breast cancer? We decided to do a TOMO in the diagnostic work up first. We can go through the TOMO. Did it help you in this case? There's still some architecture distortion here. Is it just scar? We didn't know, so we decided to Tyson and there was no enhancement in front of the clips. We have here some artefact it here. This happens sometimes if the if there's an inconstancy in the thickness. But as you can see in the FFDM there's nothing there. So you can just say it's an artefact. Sometimes it is the case and so we rated this as pirates too, because there is no enhancement and she was there a few weeks ago again and everything is still OK. And here's the CCU. This is a vessel here which is enhancing of course. OK, then we go to case number 9. No breast here. ACT scan because of an upside down stomach. You can see it here and what we found as well in the CT scan is the tumour here in the right breast. And This is why she was sent to us, and this is her mammogram. What do you think? Just one lesion or more? We compare again the FGT and on the right side we have here more tissue than on the left side. That should catch your attention. What we have done next is an ultrasound and we found of course the mass here, suspicious lymph nodes, but also the small hyper hypoechoic lesions in the biopsy. It was an invasive ductal carcinoma grade 2, this lymph angiosis and also of course the lymph node metastasis. And we look at the Tysem again and here it's really easy to see, especially in the clear stem image that we have the tumor here and the SIGMENTAL non mass enhancement. This is really nice displayed and I think better displayed than the former one. And here the CC view, same image impression, very nice pronounce enhancement here. So I think we can go to the next case, case number 10, we have a 46 year old woman. And in the safe examination it revealed a yeah path of a mass and mammography, ultrasound and biopsy was already conducted in another hospital. This is the ultrasound invasive ductal carcinoma Grade 1 and she wanted to have a surgery in our hospital. This is the mammogram of the patient. You see the speculated mass here and also some tissue there and there more symmetric then compared to the last case. And this is the type image. And here we have BP on sides. If you compare both breasts and the tumour here and here in this case, we are pretty sure that's just that one tumour, nothing else. Because the tumour is enhancing more than the benign tissue. And this is even pronounced with the new software with the clear stem. The difference between the background and the tumour is really easy to see here. CC View. The preoperative fire marking and the specimen and then we go to case number 11. We have a 64 year old woman, purple mask and safe exclamation again and no history of breast cancer in the family. So close case number 10. And we go to case number 11 again, the mammogram. Again here that and that of course, and the lymph node metastasis. And of course we found the lesion here and here's another small lesion near to the bigger one and here's some more. And this is the lymph node, which is a represents A lymph node metastasis. And this is the Tyson image very corresponding to our impression what we had from the ultrasound that we have one big lesion, then a smaller one nearby and that one here a little bit more far away. And especially in this case, again, the small lesion here is more pronounced in comparison to the background here and also this fan enhancement there and the smaller one here. Same in the CC view. And we decided to biopsy both lesions, the bigger one and of course the lymph node and the smaller one. Here's the clip marking here and there because if the tumour is smaller than one centimetre, we biopsy it and we want to show that we are in the right position. And it was both triple negative breast cancer grade 3 and of course the lymph node metastasis. And she has to undergo new Advent chemotherapy. Any questions so far? No. Then we go to case number 12. We have a 67 year old woman and the mammography was already conducted in a private practice over gynecologist. And he sent the patient to us, the woman, because of that here. Anything else what catches your attention? We found. Not so easy to see on the MLO. It was more pronounced in the CC view and this is the prior here, it's also in your workstation I think and there's no distortion here and the prior and in the ultrasound we found this mass here about two centimetre. We decided to do a Tyson to exclude that there's something suspicious in the right breast. Well, because we didn't saw that it's a tumour in the right breast or anything suspicious. It was just a small tissue there and we see the enhancement of the tumour on the left side. Of course, in both views we biopsied it. It was invasive labracarcinoma grade 2 and we placed the clip inside because she has to underwent undergo chemotherapy and the right press rated as virus 2 because we had no enhancement where the small tissue was in the prefectural fat. OK, we go towards the last case, case number 13, an older woman, 83 years old, and she presented with a rejection of the nipple. Can we look at the? And that's here. Then we did a Tyson next. Of course we see this tumor here enhancing this is the nipple, perhaps some more small little mass as well here and some more faint enhancement there and this is here easier to see in the clear SMS in the former software version. But we have also something suspicious here in the FFTM, same in ACC view humour, suspicious enhancement there and here nipple perhaps some small little mess there as well. This is the Tomo. You see some little kegs here where the enhancement was and we decided of course to biopsy both things. The tumor was an invasive labor carcinoma grade 2 and the kegs represented focal epithelia atopia, but we had this enhancement there. So both things of course were marked with the wire preoperatively and she has to undergo resection of the central segment, including the nipple, of course, because it was reflected on some little mass behind it.

2020 2025 25 25/56 20 60) 2023 2024 11 Vendor Workshop at RSNA 2025 The role of contrast-enhanced mammography (CEM) in personalized breast diagnostics Dr. Sabine Ohlmeyer University Hospital Erlangen, Germany Case 1 60-year-old woman shop at RSNA 2025 No complaints Screening mammogram (after a screening break) st-en 60-year-old woman RMLO LMLO RCC Jniversity Hospital Erlangen, Germany Anything suspicious? US US Ultrasound 2:00 50mm MA ASC 2 TICEM TiCEM vs ClearCEM ClearCEM Low-Energy cm MRI left breast BCT: ILC, G2 SIEMENS Case 2 73-year-old woman Screening mammography after break of 5 years Mammography of 2025 Ultrasound right breast LMLO L-MLO R-CC# Left breast: IDC G1, HR+, low Right breast: Mastopathy, grade DCIS microcalcifications -> benign 7:00 40mm MA Left breast: mastectomy Right breast: lumpectomy invasive tubular carcinoma, ILC and DCIS, non in sano Followed by mastectomy with 4,5 cm DCIS in specimen Case 3 49-year-old woman Suspicious palpable mass in upper outer quadrant of right breast No breast cancer in family history No breast er in fami er in family history FAU US Us IS US Mammography of private praxis Anything suspicious? Breast Density d -> Ultrasound External reports of Ultrasound guided biopsy: to less tissue and benign in re-bioposy HERD 9:00 30mm MA Tomosynthesis and TiCEM Tomo biopsy vertical arm, from lateral position and MLO Tomo guided biopsy us Prinding ILC G1 with LCIS BCT after wire localisation Current Case 4 71-year-old woman Palpable tumor behind the nipple No history of breast or ovarian cancer Mammography L-CC L-MLO# IDC G3 Mastopathy, benign MD-Board: L-ML nCT, follows by BCT and RTX LML Case 5 52-year-old woman Suspicious mass was found in ultrasound in routine check-up outine check-up TiCEM Tomosynthesis and Mags R-CC Tomo-guided biopsy from LM Sclerosing adenosis Case 6 43-year-old woman Breast cancer in family (2x, > age of Palpable mass in left breast and palpable lymph node left axilla with pain -MLO BPE! And what about MRI? MIP 1. Sub 2:00 100mm MA MIP b1500 MIP b2500calc Procedere Same tumor subtype: IDC G3 CT2 (m=2) cN1 Outcome: complete remission in MRI and histology report km Case 7 56-year-old woman Calcs in right breast since the age of 40, now more pronounced No history of breast cancer in her family Ultrasound: nothing suspicious Tomosynthesis right breast and tomo guided biopsy DCIS, high grade Case 8 69-year-old woman Breast Cancer in the right breast 2020 Neoadjuvant Chemo, BCT, RT Mammography of annual follow-up after breast cancer Mammography of July 2023 (prior) and 2024 (current) Report of mammography in 2024: increasing focal asymmetry ventral of the clips Tomosynthesis of right breast cc view Tomosynthesis in cc view for clarification Report of tomosynthesis of right breast Persisting suspicious architectural disorder Further evaluation with CEM: Scar vs recurrence of breast cancer R-MLO No suspicious enhancement BIRADS 2: Scheduled for annual follow-up Case 9 72-year-old woman Suspicious breast lesion in CT-Scan because of upside-down stomach IDC G2 with lymphangiosos and lymph node metastasis 2:00 40mm MA Clear Case 10 46-year-old woman Self-examination revealed palpable mass Mammography, ultrasound and biopsy was conducted in other hospital (IDC G1) Patient's wish for surgery in our hospital palpa Mam biop hosp Patie R-MLOF Wire marking and specimen from surgery Case 11 64-year-old woman Palpable mass in self-examination No history of breast cancer in family 10:00 70mm MA ClearCEM with MAMMC Biopsy of both mass lesions and one lymphnode IDC (TNBC) G3 with lymph node metastasis > nCT Case 12 67-year-old woman Mammography conducted in a gynecologist's private praxis Priors (2023) and Ultrasound 12L3 TiCEM for clarification 10:00 40mm MA Left breast: ILC G2 > nCT Right breast: BIRADS 2 Case 13 83-year-old woman Presented with retraction of the nipple ClearCEM with MAMMOMAT MAMMOMAT Low-Ene Tomo left breast Tomo VAB of the calcs and ultrasound biopsy of the mass Calcs: B3: FEA Mass: ILC G2 BCT BCT: Resection of the central segment including the nipple Siemens Healthineers AG, 2025 ClearCEM with MAMMOMAT B.brilliant VA11 is pending 510(k) clearance and is not yet commercially available in the U.S. and other countries. Other products/features mentioned herein are not commercially available in all countries. Their future availability cannot be guaranteed. The statements by customers of Siemens Healthineers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" setting and many variables exist (e.g ., hospital size, samples mix, case mix, level of IT and/or automation adoption) there can be no guarantee that other customers will achieve the same results. The speakers and/or their employer receive financial support from Siemens Healthineers for collaborations. All rights, including rights created by patent grant or registration of a utility model or design, are reserved. Healthineers