Fig. 34.1
Example of an analog mammography and the low energy and recombined CESM image (CC-view) showing a 6 cm mucinous carcinoma in a 75 year old woman with a palpable mass in the left breast. CESM images have been aquired on an a-Si based full field digital mammography Prototype CESM (GE Senographe DS, Chalfont St. Giles, UK). Now a FDA approved product (Senobright) for additional workup of inconclusive MX and US
Contrast Agent Administration
For contrast enhanced mammography iodinated X-ray contrast agents are used. Usually a concentration of 300 mg/ml Iodine and a dose of 1.5 ml/kg body weight (minimum 50 ml, maximum 120 ml) is sufficient.
The patient should be consented for the injection according to local protocols which include informing her about the possible side effects and asking about her medical history to identify possible contraindications. If there is no contraindication an intravenous line should be inserted, preferably into the anticubital vein. It is recommended to test this line with about 10 ml sodium chloride injected manually for confirming correct placement and flow. If the line is working well, this cannula will be connected to an automatic injector ideally.
The contrast agent is injected with a flow rate of about 3 ml/s. If the vessel is noted to be very small or the injection is difficult when testing the venous access before the contrast injection, the injection speed may need to be adapted. A saline flush of 20–30 ml can be considered after contrast medium injection, but it is not mandatory.
Iodinated contrast agents are used frequently in clinical practice and are generally considered safe. Nevertheless there are some contraindications and side effects the patient has to be informed about or they have to be ruled out before doing the examination. Low and iso-osmolar, non-ionic contrast agents are preferable as they tend to have fewer side effects.
There are several contrast agents with different iodine concentrations available on the market. An overview is displayed in Table 34.1.
Table 34.1
Commonly used iodinated contrast agents
Compound | Name | Type | Iodine content | Osmolality | |
|---|---|---|---|---|---|
Ionic | Iothalamate meglumine (Conray)Mallinckrodt | Monomer | 325 mg/ml | 1,843 | High |
Ionic | Ioxaglate (Hexabrix) Guerbet | Dimer | 320 mgI/ml | 580 | Low |
Non-ionic | Iopamidol (Isovue 300) Bracco | Monomer | 300 mgI/ml | 616 | Low |
Non-ionic | Iohexol (Omnipaque 350) GE | Monomer | 350 mgI/ml | 884 | Low |
Non-ionic | Ioversol (Optiray) Guerbet | Monomer | 300 | 651 | Low |
Non-ionic | Ioxilan (Oxilan 300) Guerbet | Monomer | 300 mgI/ml | 610 | Low |
Non-ionic | Iopromide (Ultravist 300–370) Bayer | Monomer | 300–370 mgI/ml | 610–774 | Low |
Non-ionic | Iodixanol (Visipaque 320) GE | Dimer | 320 mgI/ml | 290 | Low |
Non-ionic | Iobitridol (Xenetix 300) Guerbet | Monomer | 300 mgI/ml | 695 | Low |
Contrast Agent Side Effects
Contrast Medium Nephrotoxicity
Administration of contrast agents to patients suffering from Kidney dysfunction can result in kidney failure. The patient should be asked about any known kidney disease and the kidney function should be tested with a blood test before doing the examination, especially if the patient is elderly or has any history of kidney disease or elevated serum-creatinine levels especially related to diabetic nephropathy. Also dehydration, age over 70 years, congestive heart failure and concurrent administration of nephrotoxic drugs like non-steroid anti-inflammatory medicine can increase the risk [16].
If the creatinine levels are acceptable but the patient has risk factors, the patient should be well hydrated. Nephrotoxic drugs should be stopped for 24 h and alternative imaging modalities should be considered.
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