Phantom study to evaluate contrast-medium-enhanced digital subtraction mammography with a full-field indirect-detection system.

This phantom study simulates contrast-medium-enhanced digital subtraction mammography (CEDM) and compares subtracted image quality and total mean glandular dose for two alternative spectral combinations available in a GE Senographe DS mammography unit. The first choice takes advantage of large iodine attenuation at low photon energies and uses traditionally available spectra (anode/filter combinations Mo/Mo at 25 kV and Rh/Rh at 40 kV, "Mo25-Rh40"). The second choice, selected from a previous analytical optimization, includes harder spectra obtained by adding external filtration to traditional beams (Rh/Rh at 34 kV and Rh/Rh+5 mm of Al at 45 kV, "Rh34-Rh45H"). Individual images of a custom-made phantom containing tubes of various diameters filled with water- or iodine-based contrast agent were acquired with both spectral combinations. The total breast entrance air kerma, considering subtraction of two images, was limited to 8.76 mGy (1 R). The results were compared to predictions obtained through an analytical formalism that assumes noise of stochastic origin. Individual images were evaluated and subtracted under five combinations of temporal and dual-energy modalities. Signal variance analysis in individual raw images showed important contributions of nonstochastic origin, associated with the software applied to raw images, the curved geometry, and strong attenuation of the phantom cylindrical iodine-filled tubes, causing experimental SNR to vary from 2.2 to 0.8 times the predictions from low to high values of SNR. Iodine contrast in the subtracted images was found to be mainly defined by the spectra, independent of exposure, and linearly dependent on the iodine mass thickness. The highest contrast was obtained with the combined dual-energy temporal subtraction with Rh34-Rh45H, its value was 7% larger than the highest value measured with Mo25-Rh40. As expected, temporal modalities (single and dual energy, any spectral choice) led to higher contrast-over-noise ratio (CNR) than nontemporal dual-energy subtraction, the latter being negligibly small with Mo25-Rh40. CNR for 4 mg iodine/cm2 imaged temporally in a dual-energy fashion with Rh34-Rh45H (iodine imaged at high energy) is about 1.7 times the optimum for Mo25-Rh40 (iodine imaged at low energy). Iodine thicknesses needed to fulfill Rose's criterion were 0.78 +/- 0.02 mg iodine/cm2 for Mo25-Rh40 and 0.54 +/- 0.17 mg iodine/cm2 for Rh34-Rh45H, both lower than the proposed biological concentration of iodine in breast tumors after contrast medium administration. Although similar dose levels were obtained with both spectral choices under dual-energy (temporal and nontemporal) subtraction, the dose obtained in single-energy temporal subtraction with the Mo25 spectrum was 1.2 mGy lower than the dose from the modality offering the highest CNR. In all results considered, the spectral choice Mo25-Rh40 was found to represent an interesting alternative to the use of high-energy hardened spectra for CEDM, particularly when performing dynamic studies of the contrast-agent uptake in breast lesions.