European Radiology

, Volume 26, Issue 6, pp 1575–1581 | Cite as

Contrast-enhanced dual energy mammography with a novel anode/filter combination and artifact reduction: a feasibility study

  • Thomas Knogler
  • Peter Homolka
  • Mathias Hörnig
  • Robert Leithner
  • Georg Langs
  • Martin Waitzbauer
  • Katja Pinker-Domenig
  • Sabine Leitner
  • Thomas H. Helbich



To demonstrate the feasibility of contrast-enhanced dual-energy mammography (CEDEM) using titanium (Ti) filtering at 49 kVp for high-energy images and a novel artefact reducing image-subtraction post-processing algorithm.


Fifteen patients with suspicious findings (ACR BI-RADS 4 and 5) detected with digital mammography (MG) that required biopsy were included. CEDEM examinations were performed on a modified prototype machine. Acquired HE and low-energy raw data images were registered non-rigidly to compensate for possible subtle tissue motion. Subtracted CEDEM images were generated via weighted subtraction, using a fully automatic, locally adjusted tissue thickness-dependent subtraction factor to avoid over-subtraction at the breast border. Two observers evaluated the MG and CEDEM images according to ACR BI-RADS in two reading sessions. Results were correlated with histopathology.


Seven patients with benign and eight with malignant findings were included. All malignant lesions showed a strong contrast enhancement. BI-RADS assessment was altered in 66.6 % through the addition of CEDEM, resulting in increased overall accuracy. With CEDEM, additional lesions were depicted and false-positive rate was reduced compared to MG.


CEDEM using Ti filtering with 49 kVp for HE exposures is feasible in a clinical setting. The proposed image-processing algorithm has the potential to reduce artefacts and improve CEDEM images.

Key Points

CEDEM with a titanium filter is feasible in a clinical setting.

Breast thickness-dependent image subtraction has the potential to improve CEDEM images.

The proposed image-processing algorithm reduces artefacts.


Breast cancer Digital mammography Contrast-enhanced digital mammography Image processing Contrast agent 





Contrast-enhanced dual-energy mammography




Full-field digital mammography


High energy


Kilovolt peak


Low energy






Signal-difference-to-noise ratio







The scientific guarantors of this publication are Thomas H. Helbich, MD. and Thomas Knogler, MD. The authors of this manuscript declare relationships with the following companies: Siemens Healthcare, Erlangen, Germany, and Bracco, Italy. This study has received funding from: Siemens Healthcare, Erlangen, Germany and Bracco, Italy. No complex statistical methods were necessary for this paper. Institutional Review Board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Methodology: prospective, experimental, performed at one institution.


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Copyright information

© European Society of Radiology 2015

Authors and Affiliations

  • Thomas Knogler
    • 1
    • 2
  • Peter Homolka
    • 4
  • Mathias Hörnig
    • 5
  • Robert Leithner
    • 4
  • Georg Langs
    • 1
    • 3
  • Martin Waitzbauer
    • 1
    • 3
  • Katja Pinker-Domenig
    • 1
    • 2
  • Sabine Leitner
    • 1
    • 2
  • Thomas H. Helbich
    • 1
    • 2
  1. 1.Department of Biomedical Imaging and Image-Guided TherapyMedical University of ViennaViennaAustria
  2. 2.Division of Molecular and Gender ImagingMedical University of ViennaViennaAustria
  3. 3.Computational Imaging Research LaboratoryMedical University of ViennaViennaAustria
  4. 4.Center for Medical Physics and Biomedical EngineeringMedical University of ViennaViennaAustria
  5. 5.Siemens AG, Healthcare, X-Ray ProductsErlangenGermany

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