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Background Mammographic focal asymmetry represents normal breast tissue, benign, or malignant lesions. Accurate characterization is important for better management. The study evaluates diagnostic accuracy of contrast-enhanced digital mammography (CEDM) for characterization of focal asymmetries seen in 2D mammography. Results The study was done prospectively on 38 females among 360 patients who underwent baseline sonomammographic assessment for diagnostic and screening purposes. Complementary ultrasound was performed only when a finding was detected in cases of screening mammograms. Focal asymmetries were evaluated according to Breast Imaging Reporting and Data System (BI-RADS) lexicon 2013. CEDM was performed and followed by ultrasound (US) guided core biopsy for solid lesions or aspiration for cystic lesions. CEDM processing resulted in recombined image showing enhancing abnormality. Low energy image and recombined image findings were analyzed blindly and classified into focus enhancement, mass enhancement, non-mass enhancement, and non-enhanced lesions. CEDM and sonomammography findings were compared regarding pathological probability and multiplicity. Histopathology was the reference standard. Mass enhancement showed strong correlation with malignant pathology. Non-mass enhancement showed no correlation with particular pathology. All non-enhanced focal asymmetries were benign in pathology or normal tissue. Rim enhancement needed second look ultrasound evaluation. CEDM was superior to sonomammography with higher sensitivity (77.8%, 65.7% respectively), NPV (0.8, 0.6), accuracy (0.6, 0.2) but lower specificity (81.8% vs. 100%). Multiplicity detection by CEDM was 26.3% and by sonomammography was 10.5%. Conclusion CEDM is more accurate than sonomammography in determination of normal tissue, benign, or malignant lesions in cases of mammographic focal asymmetry. CEDM is more accurate in detection of multiplicity. Undesired biopsies were avoidable with proper management of suspicious and malignant lesions.

Diagnostic accuracy of contrast-enhanced digital mammography in comparison with sonomammography for characterization of focal asymmetries