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The conspicuity of enhancing lesions on CEM recombined images was graded (low, moderate, or high) by one or both breast radiologists assigned as readers for the study, blinded to two-year imaging follow-up or biopsy pathology results. The positive predictive value (PPV) for malignancy was determined for each level of conspicuity.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Across 476 CEM examinations in 455 women (median age, 49 years; IQR: 44\u201357), there were 563 enhancing lesions (55 malignant, 508 benign). Of the 563 enhancing lesions, 52% (292\/563) were low conspicuity, 38% (213\/563) moderate, and 10.3% (58\/563) high. The PPV to predict cancer was 9% (95% CI: 6\u201312%), 11% (95% CI: 7\u201316%), and 10% (95% CI: 4\u201321%) for low, moderate, and high conspicuity (low vs high,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.68; low vs moderate,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.34; moderate vs high,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.83). Of the 55 cancers, most high-conspicuity cancers presented on both recombined images and low-energy images (5\/6; 83%), while most low- (21\/25; 84%) and moderate-conspicuity cancers (17\/24; 71%) presented on recombined images only (\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.006). Inter-reader agreement was almost perfect for 100 lesions graded by both breast radiologists (\u03ba\u2009=\u20090.94).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Lesion conspicuity is not independently associated with malignancy. Most enhancing lesions, including most cancers, show low or moderate conspicuity on CEM.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Is lesion conspicuity on CEM, determined on the recombined images, an independent predictor of malignancy<\/jats:italic>\n                      ?\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>The PPV for low, moderate, and high conspicuity to predict malignancy was 8.6%, 11.3%, and 10.3%, respectively (non-significant differences between low, moderate, and high conspicuity)<\/jats:italic>\n                      .\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Lesion conspicuity is not an independent predictor of malignancy. Enhancing lesions seen on recombined images should not be considered benign based on low conspicuity alone, as most low-conspicuity cancers presented with enhancement only and lacked a correlate finding on low-energy images<\/jats:italic>\n                      .\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-026-12660-y","type":"journal-article","created":{"date-parts":[[2026,6,13]],"date-time":"2026-06-13T07:14:13Z","timestamp":1781334853000},"page":"7864-7873","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Clinical significance of lesion conspicuity on contrast-enhanced mammography"],"prefix":"10.1007","volume":"36","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7004-7793","authenticated-orcid":false,"given":"Tali","family":"Amir","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carol H.","family":"Lee","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Molly P.","family":"Hogan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah","family":"Eskreis-Winkler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Varadan","family":"Sevilimedu","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel J.","family":"Long","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noam","family":"Nissan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Victoria L.","family":"Mango","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kimberly N.","family":"Feigin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maxine S.","family":"Jochelson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher E.","family":"Comstock","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Janice S.","family":"Sung","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,13]]},"reference":[{"key":"12660_CR1","doi-asserted-by":"publisher","first-page":"1231","DOI":"10.1016\/j.acra.2023.10.027","volume":"31","author":"T Amir","year":"2024","unstructured":"Amir T, Pinker K, Sevilimedu V et al (2024) Contrast-enhanced mammography for women with palpable breast abnormalities. 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Sarah Eskreis-Winkler reports being a consultant for Medscape. Molly P. Hogan is the PI of a study funded by Aura Technologies. Maxine S. Jochelson reports being a consultant for GE. Christopher E. Comstock reports being a consultant for Bayer Medical and Recentric Healthcare Technologies. Janice S. Sung reports being a consultant for GE and Hologic. The remaining authors declare no conflict of interest.","order":2,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Varadan Sevilimedu, MBBS, DrPH, at Memorial Sloan Kettering Cancer Center, kindly provided statistical advice for this manuscript.","order":3,"name":"Ethics","label":"Statistics and biometry","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Written informed consent was waived by the Institutional Review Board.","order":4,"name":"Ethics","label":"Informed consent","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Institutional Review Board approval was obtained.","order":5,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"Patients in our study overlapped with prior retrospective studies as follows: 155 patients overlapped with Nissan et al.\u2019s study on the sensitivity and specificity of CEM in extremely dense breasts [\n                      \n                      ], 71 patients overlapped with Coffey et al.\u2019s study [\n                      \n                      ] on the utility of short-term follow-up of CEM lesions after a negative MRI, and 10 patients overlapped with Hogan et al.\u2019s study on the role of CEM in patients with a history of lobular neoplasia [\n                      \n                      ]. In addition, 9 patients overlapped with Horvat et al.\u2019s prospective study [\n                      \n                      ] on the role of supplemental whole-breast ultrasound with CEM.","order":6,"name":"Ethics","label":"Study subjects or cohorts overlap","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"order":7,"name":"Ethics","label":"Methodology","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}}]}}