CEM-Guided Biopsy of Breast Lesions in the Prone Position: The FlorentineExperience

CEM-Guided Biopsy of Breast Lesions in the Prone Position: The Florentine Experience

Contrast-enhanced mammography (CEM) has emerged as a powerful diagnostic tool in breast imaging, offering functional assessment of breast lesions through iodine-based contrast enhancement. At Azienda Ospedaliero-Universitaria (AOU) Careggi in Florence, Italy, the Breast Diagnostics Unit under the direction of Dr. Federica Di Naro has developed significant expertise in CEM-guided biopsy using the GIOTTO system, contributing to the evolving landscape of minimally invasive breast diagnosis.

Dr. Di Naro leads a multidisciplinary breast imaging service within one of Tuscany's principal academic medical centers, where the integration of advanced imaging techniques with interventional procedures supports comprehensive patient care. Her team's work with CEM-guided biopsy addresses a critical challenge in breast diagnostics: lesions visible only on contrast-enhanced imaging that remain occult on standard mammography and ultrasound.

The GIOTTO System: Technical Overview and Workflow

The GIOTTO system for CEM-guided biopsy features a prone table designed for patient comfort and optimal operator access. The interface displays three key images: the scout image providing an initial overview, the active study image for real-time analysis, and a dedicated monitor interface for the operator. A traffic light system—red, orange, and green—indicates readiness status, with green confirming ideal conditions for biopsy execution.

The procedural workflow begins with standard breast positioning and compression. Following contrast agent injection, a two-minute delay allows for optimal enhancement before resuming compression for targeted imaging. The system enables precise lesion localization, with particular attention to angles greater than 15 degrees and careful avoidance of inferior projection artifacts. Once green status is confirmed, the biopsy proceeds under local anesthesia, with clip marker placement for future surgical guidance.

Clinical Experience and Case Applications

Since December 2023, the Careggi team has performed 524 contrast-enhanced mammograms, identifying 37 lesions exclusively through CEM. Second-look evaluation with ultrasound and tomosynthesis showed correlation in only 30 of 110 additional lesions, underscoring the essential role of CEM-guided biopsy for definitive diagnosis.

Clinical cases demonstrate the system's utility across scenarios including presurgical staging, problem-solving in dense breast tissue, and evaluation of non-mass enhancement. In one case, a BI-RADS 5 lesion with no morphological correlate on standard imaging was successfully biopsied using CEM guidance, revealing invasive carcinoma. Another case involved presurgical staging where additional non-mass enhancement in the contralateral breast was identified and biopsied, confirming ductal carcinoma.

Advantages and Positioning in Clinical Practice

CEM-guided biopsy offers several advantages over MRI-guided procedures: shorter procedural time, lower cost, wider availability, and greater familiarity for radiologists accustomed to mammographic techniques. Radiation dose for single acquisitions remains within established safety limits, though careful patient selection is necessary given positioning constraints and cumulative dose considerations with multiple views.

As CEM utilization increases while MRI remains stable in clinical practice, CEM-guided biopsy represents an accessible, efficient solution for lesions identified only through contrast-enhanced mammography. The Florentine experience demonstrates that systematic implementation of this technology enhances diagnostic accuracy, improves patient staging, and supports multidisciplinary breast cancer care pathways.

Keywords: CEM-guided biopsy, contrast-enhanced mammography biopsy, GIOTTO system breast biopsy, prone position breast biopsy, Federica Di Naro AOU Careggi, breast lesion biopsy Florence, CEM versus MRI biopsy, minimally invasive breast diagnosis, BI-RADS 5 lesion biopsy, breast cancer staging Italy, contrast-enhanced mammography Italy, breast imaging Tuscany.