TiCEM Pictorial Atlas - Preoperative staging of disease extent

SIEMENS Healthineers TiCEM Pictorial Atlas Preoperative staging of disease extent Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Preoperative staging of disease extent SIEMENS Healthineers In preoperative staging of women with newly diagnosed breast cancer, contrast-enhanced mammography (CEM) can be used as a cost-efficient and more easily accessible alternative to MRI as it already contains information from SIEMENS Healthineers both an FFDM examination (in the LE image) and a vascular image.1 A recent study has demonstrated that both CEM and MRI detected areas of multifocality and multicentricity at a similar rate.2 Another study showed a change in surgical plan in 25% of patients based on additional CEM evaluation.3 This suggests that CEM is a useful addition to preoperative staging that helps define better surgical management without increasing delay in the treatment pathway. 1 Jochelson MS, Lobbes MBI. DOI: 10.1148/radiol.20212019482 2 Steinhof-Radwańska K et al. DOI: 10.3390/curroncol28050341; see also: Jochelson MS, Lobbes MBI. DOI: 10.1148/radiol.20212019482 2 3 Montrognon F et al. DOI: 10.1259/bjr.20210765; see also: Covington MF et al. DOI: 10.1093/bjr/tqae017 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Preoperative staging of disease extent SIEMENS Healthineers Cases 1 2 3 4 Palpable lump right Screening mammogram: suspect architectural Further diagnostic of Rouge Lymph Node breast distortion abnormality left and IDC G2 5 6 7 Invasive carcinoma, Invasive mammary Invasive ductual positive left axillary carcinoma with dermal carcinoma and lymph nodes metastasis intraductual papilloma 3 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 1 Invasive ductal carcinoma, grade 2, multifocality Study ID: 1aac467 Study ID: 1aac469 back Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 1 SIEMENS Invasive ductal carcinoma, grade 2, multifocality Healthineers Clinical information • 62-year-old • Recalled from screening due to a palpable mass in the outer quadrant of the right breast • Breast density type - B LE LE 5 Study ID: 1aac467 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 1 SIEMENS Invasive ductal carcinoma, grade 2, multifocality Healthineers Assessment Y • TiCEM exam: Confirmation of one asymmetrical mass in the outer quadrant of the right breast • Detection of 4 other foci (arrows) showing variable enhancements on total diameter of ~70mm • BI-RADS: Right breast - BI-RADS 5 Left breast - BI-RADS 1 • Pathology: Right breast: 9 o´clock: IDC, G2 / 10 o´clock: IDC, G 3 LE TiCEM 6 Study ID: 1aac469 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 2 Screening mammogram: suspect architectural distortion back Study ID:3bbb14 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 2 SIEMENS Screening mammogram: suspect architectural Healthineers distortion 2021 Clinical information • 69-year-old • Annual screening mammogram • Recalled from screening due to a palpable mass in the outer quadrant of the right breast • Breast density type – B 2022 • Area of architectural distortion suspected on screening mammogram LE LE 8 Study ID:3bbb14 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 2 SIEMENS Screening mammogram: suspect architectural distortion Healthineers RT BREAST ANTIRADIAL 11:00 RT BREAST RADIAL 9:00 1 cm fn RT BREAST ANTIRADIAL 8:00 5 cm fn US US DBT DBT 9 Study ID:3bbb14 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 2 SIEMENS Screening mammogram: suspect architectural distortion Healthineers LE LE TiCEM LE LE 10 Study ID:3bbb14 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 2 SIEMENS Screening mammogram: suspect architectural Healthineers distortion Pathology Y • Confirmed with stereotaxis the same day • Site A: Posterior, DCIS grade 2 • Site B: Anterior, DCIS grade 2 Teaching Points • Shortened diagnostic work-up time • Extent of disease determined at time of first biopsy • Patient ready to move on to the surgeons TiCEM TiCEM IN2D IN2D 11 Study ID:3bbb14 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 3 Further diagnostic work-up of abnormality left back Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers Clinical information • 71-year-old • Presents from outside facility for bilateral screening • Left: Abnormality • Original films were reviewed, and she was brought back for a full bilateral assessment to begin with TICEM FFDM DBT FFDM 13 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers TiCEM TiCEM SHS DI XP 14 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers DBT LE TiCEM LE DBT SHS DI XP 15 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers RT BREAST AXILLA RADIAL RT BREAST 12:00 4 cm fn ANTIRADIAL S 3 RT BREAST 11:00 5 cm fn ANTIRADIAL RT BREAST 2:00-3:00 4 cm fn RADIAL TiCEM US Study ID: 2bbb05 SHS DI XP 16 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers TiCEM MRI SHS DI XP 17 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers 1 2 1.0 2.0 3 3.0 LT BREAST 12:00 3 cm fn ANTIRADIAL LT BREAST 11:00 4 cm fn ANTIRADIAL S 0.0 1 3 O 2 +Dist 1.0 2.0 O 3 3.0 LT BREAST 8:00 2 cm fn ANTIRADIAL LT BREAST AXILLA ANTIRADIAL TiCEM US Study ID: 2bbb05 SHS DI XP 18 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers TiCEM MRI SHS DI XP 19 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 3 SIEMENS Further diagnostic work-up of abnormality left Healthineers Pathology Y • Right: ILC, G2 • Left: IDC, G2 Conclusion • TiCEM depicted additional ipsi- and contralateral cancers • Good correlation with MRI TiCEM 20 Study ID: 2bbb05 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 4 Rouge Lymph Node and IDC G2 back Study ID: 3bbb20 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers Clinical information • 61-year-old, OSFOR* • Recent biopsy of 7 mm spiculated high density mass along the anterior pectoralis: IDC, G2 • LN enlarged in axilla and ipsilateral breast • Patient brought back for TICEM, axillary and US • Same day biopsy work-up • Using TICEM to confirm correct biopsy target DBT DBT 22 Study ID: 3bbb20 * Outside Film for Overread Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers Patient came with prior Mammograms, Ultrasound BREAST 1 Originally biopsied only the BREAST 1 TISO.2 TISO 2 MIO. 7 L18-5 L'18-5 40Hz RS 40Hz RS spiculated mass lying along Z 1.0 2D 59% Dyn R 68 the pectoralis muscle: P Low HGen TAC1 X4 IDC, G2 ER+ PR+ Dist 0.855 cm 11 CM from Nipple SAG Dist 1.15 cm SAG 3CM from Nipple Dist 0.793 cm LEFT BREAST LEFT BREAST Trans BREAST 1 TISO.2 MIO.Z L'18-5 40Hz RS Z 1.0 19 Dist 0.816 cm Dist 0.660 cm 13CM from Nipple Dist 0.580 cm Left Axilla Trans SAG DBT US Study ID: 3bbb20 SHS DI XP 23 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers Patient came with prior outside MRI RIGHT LEFT MRI Primary cancer Abnormal lymph nod Abnormal intramammary lymph nod Enhancement central breast? Lymph nod MIP = Max. Intensity Projection Study ID: 3bbb20 SHS DI XP 24 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers We started with TiCEM: Finding: • One view is often more enhancing than the other • 3 areas of enhancement • The intermammillary LN does NOT enhance • A second area is noted superior and lateral to it, with no MRI correlate LE TiCEM LE 25 Study ID: 3bbb20 SHS DI XP Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers Pathology Y Axillary LN: Metastatic Mammary Carcinoma ER + (100%), PR - (0%), E- LT AXILLA ANTIRADIAL cadherin LT BREAST RADIAL 2:00-3:00 3 cm f Original Tumor: ER +, PR +, E-cadherin + 0.0 LEFT Breast Asymmetry: 1.0 Stromal fibrosis with small LT BREAST RADIAL AXILLARY TAIL 1:00 foci of LCIS 2.0 LT BREAST ANTIRADIAL 3:00-4:00 3 cm fn Intramammary LN: US TiCEM negative for malignant cells 26 Study ID: 3bbb23a Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 4 SIEMENS Rouge Lymph Node and IDC G2 Healthineers Comment The area of vague enhancement towards the 2:00 - 3:00 position acts like ILC. Did we just biopsy the wrong area, believing the US correlated with the mammogram? How to answer this question? Repeat the TiCEM, look at the clip position. Could we just use post- Suspicious Enc+ biopsy images? No, there is too much post biopsy reaction, as this patient was biopsied 3 times that day. So, we brought her back to see if the TiCEM TiCEM clip correlated with the non mass enhancement towards 2:00 – 3:00. 27 Study ID: 3bbb23a Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 5 Invasive carcinoma, positive left axillary lymph nodes back Study ID: 3bbb02 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 5 SIEMENS Invasive carcinoma, positive left axillary lymph Healthineers nodes Clinical information • 58-year-old presented outside with a lump in her left breast • Imaging and biopsy: invasive carcinoma of no specific type with positive axillary lymph nodes • Family history: Maternal aunt in 40s • Patient was referred to our facility for surgical consultation Recorded case discussion in this Learning Path (Contrast Enhanced Mammography DBT DBT Integration Case 1) 29 Study ID: 3bbb02 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 5 SIEMENS Invasive carcinoma, positive left axillary lymph nodes Healthineers TiCEM TiCEM 30 Study ID:3bbb02 SHS DI XP Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 5 SIEMENS Invasive carcinoma, positive left axillary lymph Healthineers nodes Pathology Y • Invasive carcinoma, No special type Grade 2/3 • • ER/PR positive Teaching Points • "The Works": • Mass Enhancement • Non-Mass Enhancement • Skin Involvement • Enhancing Lymph Nodes LE TiCEM 31 Study ID: 3bbb02 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 6 Invasive mammary carcinoma with dermal metastasis back Study ID:3bbb03 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 6 SIEMENS Invasive mammary carcinoma with dermal Healthineers metastasis Clinical information • 80-year-old female • Recently diagnosed with breast cancer, for surgical consultation/completion of work-up Recorded case discussion in this Learning Path (Contrast Enhanced Mammography LE LE Integration Case 2) 33 Study ID:3bbb03 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 6 SIEMENS Invasive mammary carcinoma with dermal metastasis Healthineers LE TiCEM LE 34 Study ID:3bbb03 SHS DI XP Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 6 SIEMENS Invasive mammary carcinoma with dermal metastasis Healthineers 0.0 S 0.0 1.0 1.0 Dist -Dist 2.0 2.0 3.0 30 RT BREAST RADIAL 8:00-9:00 5 cm fn S 0.0 RT BREAST RETROAREOLAR RADIAL 1.0 2.0 3.0 RT AXILLA RADIAL RT AXILLA POST FIRE PASS 1 4.0 LE LE US Study ID:3bbb03 SHS DI XP 35 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 6 SIEMENS Invasive mammary carcinoma with dermal Healthineers metastasis Pathology Y • Skin lesion: Dermal metastasis • Right axillary node: positive • Prior mass biopsied: invasive carcinoma grade 1 Teaching Points • All enhancing lesions should be pursued! 07 LE LE 36 Study ID:3bbb03 Study ID: Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Case 7 Abnormal screening, work- up, biopsy, and surgical consultation back Study ID: 3bbb04 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 7 SIEMENS Invasive ductal carcinoma and intraductal Healthineers papilloma Clinical information • 63-year-old from outside facility • Abnormal screening and diagnostic work-up • Self-refers for completion of work-up, biopsy, and surgical consultation Recorded case discussion in this Learning Path (Contrast Enhanced Mammography LE TiCEM Integration Case 3) 38 Study ID: 3bbb04 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Case 7 SIEMENS Invasive ductal carcinoma and intraductal papilloma Healthineers LE TiCEM LE 39 Study ID: 3bbb04 SHS DI XP Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 7 SIEMENS Invasive ductal carcinoma and intraductal papilloma Healthineers TiCEM DBT DBT DBT 40 Study ID: 3bbb04 SHS DI XP Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 7 SIEMENS Invasive ductal carcinoma and intraductal papilloma Healthineers 0.0 0.0 -Dist 1.0 Dist 1.0 2 2.0 2.0 3 3.0 LT BREAST 2:00 7 cm fn ANTIRADIAL 3.0 LT BREAST 3:00 5 cm fn ANTIRADIAL LT BREAST 12:00 4 cm fn ANTIRADIAL S 0.0 1.0 2.0 3 LT BREAST 12:00 4 cm fn RADIAL LT BREAST 2:00 7 cm fn RADIAL US 2:00, 7.2mm US 3:00, 5.7 mm US 12:00, 6.5 mm Study ID: 3bbb04 SHS DI XP 41 Unrestricted © Siemens Healthineers, 2025 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 Effective Date: 20 Sep 2024 | QR700012717 Case 7 SIEMENS Invasive ductal carcinoma and intraductal Healthineers papilloma - 0.0 0.0 Pathology Y • Invasive ductal carcinoma 1.0 1.0 with lobular features, G2 • Intraductal papilloma 2.0 2.0 3.0 Teaching Points 3.0 • CEM changed surgical PRE FIRE PASS 1 SITE A - 4.0 PRE FIRE PASS 1 SITE B 4.0 LT BREAST 2:00 ANTIRADIAL LT BREAST 12:00 ANTIRADIAL management by finding the S 0.0 12:00 lesion, which would not have been resected at 1.0 time of surgery - 2.0 3.0 PRE FIRE PASS 1 SITE C - 4.0 LT BREAST 3:00 ANTIRADIAL US 42 Study ID: 3bbb04 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 TiCEM Pictorial Atlas SIEMENS Healthineers International classifications Breast Imaging Reporting and Data Breast composition categories* Pathological reporting for minimally System (BI-RADS)* invasive biopsies (B classification)** BI-RADS 0: Incomplete a: The breasts are almost entirely fatty B1=not usable or exclusively normal tissue BI-RADS 1: Negative b: There are scattered areas of B2=benign BI-RADS 2: Benign fibroglandular density B3=benign but with uncertain biological BI-RADS 3: Probably benign c: The breasts are heterogeneously dense, potential BI-RADS 4: Suspicious which may obscure small masses B4=suspicious of malignancy 4A: Low suspicion of malignancy d: The breasts are extremely dense, which B5=malignant 4B: Moderate suspicion of malignancy lowers the sensitivity of mammography B5a=intraductal 4C: High suspicion of malignancy B5b=invasive BI-RADS 5: Highly suggestive of malignancy B5c=not unique BI-RADS 6: Known biopsy – proven B5d=not epithelial, metastatic malignancy * American College of Radiology (ACR) Breast Imaging Reporting and Data System (ACR BI-RADS® Atlas Fifth Edition). © American College of Radiology; 2013 43 ** National Coordinating Group for Breast Screening Pathology (NHBSP). E.C. Working Group on Breast Screening Pathology, S3 Guidelines Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 TiCEM Pictorial Atlas SIEMENS Healthineers List of abbreviations ADH Atypical ductal hyperplasia MAG Magnification view CC Cranio caudal view MG Mammogram CCID CC Implant displaced view ML Mediolateral view BCT Breast conserving therapy MLO Mediolateral oblique view CEM Contrast enhanced mammography MLOID MLO Implant displaced view CNB Core needle biopsy MRI Magnet resonance tomography of the breast DBT Digital Breast Tomosynthesis NAC Neoadjuvant chemotherapy DCIS Ductal carcinoma in situ OSFOR Outside film for overread FCM Fibrocystic mastopathy R Right FFDM Full field digital mammography SCC Spot imaging CC G Grading Sl Slice (in DBT with slice number) IDC Invasive ductal carcinoma syMG Synthetic mammogram IDV Implant displaced views TiCEM Titanium contrast enhanced mammography ILC Invasive lobular carcinoma UDH Usual ductal hyperplasia ILA Invasive lobular adenocarcinoma UOQ Upper outer quadrant IN2D Insight 2D (Siemens Healthineers synthetic mammogram) US Ultrasound L Left y Year LCIS Lobular carcinoma in situ LTR Lifetime risk 44 Unrestricted © Siemens Healthineers, 2025 Effective Date: 20 Sep 2024 | QR700012717 SIEMENS Healthineers Please note this learning material is for training purposes only. 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