From Variability to Standardization: The Impact of Breast Density on Background Parenchymal Enhancement in Contrast-Enhanced Mammography and the Need for a Structured Reporting System
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Introduction
Breast density is a well-established predictor of breast cancer risk, affecting both the probability of malignancy and the sensitivity of mammography. Background parenchymal enhancement (BPE), which is observed in contrast-enhanced breast imaging, has been investigated as a potential independent biomarker for breast cancer risk. However, the literature presents conflicting results regarding its relationship with both breast density and malignancy. Unlike breast density, which is classified using the ACR BI-RADS system, BPE lacks a standardized reporting system in contrast-enhanced mammography (CEM), leading to inconsistencies in its assessment and clinical application. This study aims to determine whether breast density influences BPE in CEM and to establish a structured lexicon for BPE classification, which will enhance consistency in clinical practice and improve comparability across research studies.
Materials and Methods
This retrospective study included 213 patients who underwent CEM, mammography (MG), and ultrasound (US) between May 2022 and June 2023 at the P.O. ‘A. Perrino’ Hospital, Brindisi. BPE was categorized into four levels (Minimal, Light, Moderate, and Marked), while breast density was rated according to the ACR BI-RADS (A–D) classification. Statistical analysis was performed to assess the correlation between BPE and breast density, with the findings supporting the need for a BPE-CEM Standard Scale (BCSS) to standardize reporting and improve clinical consistency.
Results
Among the 213 patients, 57% exhibited minimal BPE, 31% light BPE, 10% moderate BPE, and 2% marked BPE. Higher breast density (ACR C–D) was significantly associated with increased BPE levels, while lower breast density (ACR A–B) correlated with lower BPE levels. Regression analysis confirmed a significant positive correlation (p < 0.05) between breast density and BPE, with no significant association found between BPE and age. These findings underline the necessity for a standardized BPE classification system, leading to the development of the BCSS, a structured lexicon aimed at enhancing clinical reporting and interobserver agreement.
Conclusion
BPE in CEM is significantly influenced by breast density, highlighting the need for a standardized classification system. To address the current variability in reporting, we propose the BPE-CEM Standard Scale (BCSS), which aims to ensure greater consistency in both clinical practice and research. Standardizing BPE characterization will facilitate its integration into breast cancer risk assessment models. Future research should focus on validating the BCSS framework and evaluating its impact on diagnostic accuracy and clinical decision-making.
