Cancer Treatment Today » Imaging

PET to stage axillae in breast cancer – pro

M Levin, MD — Mon, 29 Oct 2012 14:50:40 +0000

It is generally accepted that stage I and II breast cancer does not require staging. Stage II is divided into stage IIA and stage IIB based on tumor size and whether it has spread to the axillary lymph nodes (the lymph nodes under the arm). In stage IIA, the cancer is either not larger than 2 centimeters and has spread to the axillary lymph nodes, or between 2 and 5 centimeters but has not spread to the axillary lymph nodes. In stage IIB, the cancer is either between 2 and 5 centimeters and has spread to the axillary lymph nodes, or larger than 5 centimeters but has not spread to the axillary lymph nodes. Whether axillae are involved is determinded by physical exam, nodal dissection or, more recently, by sentinel node scintigraphy or imaging and/or biopsy.

The sensitivity of PET to stage axillae is limited. A multicenter trial cast doubt on the early supportive studies, and more recent single-center trials performed in the era of sentinel lymph node mapping showed that, compared with sentinel lymph node biopsy, the sensitivity of FDG PET and PET/CT for axillary nodal metastases was as low as 20%–40%. Therefore, PET should not be used as an axillary staging modality

Lee JH, Rosen EL, Mankoff DA: The role of radiotracer imaging in the diagnosis and management of patients with breast cancer: Part 1–Overview, detection, and staging. J Nucl Med 50:569-581, 2009

Lovrics PJ, Chen V, Coates G, et al: A prospective evaluation of positron emission tomography scanning, sentinel lymph node biopsy, and standard axillary dissection for axillary staging in patients with early stage breast cancer. Ann Surg Oncol 11:846-853, 2004

David A. Mankoff and Jennifer M. Specht, University of Washington; Seattle Cancer Care Alliance, Seattle, WA William B. Eubank, University of Washington; Puget Sound Veterans Affairs Medical Center, Seattle, WA Larry Kessler, University of Washington, Seattle, WA [18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not?
JCO April 20, 2012 vol. 30 no. 12 1252-1254

For Lay version see here

PEM: Positron Emission Mammography – pro

M Levin, MD — Mon, 03 Sep 2012 23:33:21 +0000

Positron-emission mammography (PEM), uses isolated molecular imaging to examine the breast, producing a precise and comprehensive image tissue within. LIke for PET, F-18 tracer binding to fluorodeoxyglucose (FDG) within the breast’s cells indicates abnormailities. PEM reveals the size, shape, location and malignancy of the mass in a high-resolution 3D tomographic image.

At the 2008 Radiological Society of North America (RSNA) meeting, the single-site study of 208 women with confirmed breast cancer revealed that PEM was significantly more sensitive (93 percent) than whole-body PET (68 percent) in detecting index malignant lesions, and equivalent to breast MRI (93 percent). Of the 182 lesions detected, PEM successfully identified 90 percent of the 30 ductal carcinoma in situ (DCIS) cases, more than the 83 percent detected by MRI. PEM specificity was 74 percent versus 48 percent for MRI in the ipsilateral breast. PEM specificity was 82 percent versus 67 percent with MRI in the contralateral breast. Both PEM and MRI were 89 percent accurate in detecting index lesions in fatty breasts. Accuracy reached 77 percent with PEM in extremely dense breasts, compared with 69 percent using MRI.

Several other prospective comparative studies have been published.

Schilling K, Narayanan D, Kalinyak JE, The J, Velasquez MV, Kahn S, Saady M, Mahal R, Chrystal L.Positron emission mammography in breast cancer presurgical planning: comparisons with magnetic resonance imaging. Eur J Nucl Med Mol Imaging. 2011 Jan;38(1):23-36.

Berg WA, Weinberg IN, Narayanan D, Lobrano ME, Ross E, Amodei L, Tafra L, Adler LP, Uddo J, Stein W 3rd, Levine EA; Positron Emission Mammography Working Group.

Breast J. 2006 Jul-Aug;12(4):309-23.

David Mankoff Imaging in breast cancer – breast cancer imaging revisited, Breast Cancer Research 2005, 7:276-278

Benard F, Turcotte E: Imaging breast cancer with single photon computed tomography and positron emission tomography. Breast Cancer Res 2005, 7:153-162.

RSNA 2008: 94th Scientific Assembly and Annual Meeting of the Radiological Society of North America: Scientific Session VB31-04: Presented December 3, 2008.

Laino, Charlene RSNA Annual Meeting Newer Breast Imaging Techniques Offer Advantages over Mammography, MRI. Oncology Times:
10 February 2009 – Volume 31 – Issue 3 – pp 6-8

Computer Aided Detection (CAD) for MRI – pro

M Levin, MD — Mon, 27 Aug 2012 17:32:39 +0000

Lay Summary: CAD is still investigational for breast MRI.

The use of computer-aided detection (CAD) is proposed to supplement radiologists’ interpretation of contrast-enhanced magnetic resonance imaging (MRI) of the breast. MRI of the breast is sometimes used as an alternative to mammography or other screening and diagnostic tests because of its high sensitivity in detecting breast lesions, even among those women—for example, younger women and those with denser breasts—in whom mammography is less accurate. However, MRI has a high false-positive rate because of the difficulty in distinguishing between benign and malignant lesions. It is also used to look for more extensive disease in women diagnosed with breast cancer and to gauge the impact of treatment. Unfortunately, the literature on the use of CAD with MRI of the breast was sparse overall, and few studies addressed the specific situations in which CAD with MRI is used in a clinical setting. A recent TEC Asessment by BCBS found it to be experimental.

Based on the available evidence, the Blue Cross and Blue Shield Association

Medical Advisory Panel concluded that there is insufficient evidence to evaluate if

the use of CAD systems would maintain or increase the sensitivity, specificity, and

recall rates of MRI of the breast. The TEC assessment concluded that, given the

inability to evaluate these intermediate outcomes, it is impossible to evaluate the

impact of CAD on health outcomes such as treatment success and survival of patients with breast cancer.

http://www.bcbs.com/betterknowledge/tec/vols/21/21_04.html

Deurloo EE, Peterse JL, Rutgers EJ et al. Additional breast lesions in patients eligible for breast-conserving therapy by MRI: impact on preoperative management and potential benefit of computerized analysis. Eur J Cancer 2005;41(10):1393-401

DeMartini WB, Lehman CD, Peacock S et al. Computer-aided detection applied to breast MRI: assessment of CAD-generated enhancement and tumor size in breast cancers before and after neoadjuvant chemotherapy. Acad Radiol 2005;12(7):806-14

Breast tomosynthesis: a new mammography – pro

M Levin, MD — Fri, 24 Aug 2012 17:58:36 +0000

Breast tomosynthesis is a 3-dimensional (3-D) imaging technology that involves acquiring images of a stationary compressed breast at multiple angles during a short scan. The individual images are then reconstructed into a series of thin high-resolution slices that displayed individually or in a dynamic ciné mode. Tomosynthesis can reduce or eliminate the tissue overlap effect. While holding the breast stationary, images are acquired at a number of different x-ray source angles. Objects at different heights in the breast project differently for each angle. The final step in the tomosynthesis procedure is reconstructing the data to generate images that enhance objects from a given height by appropriate shifting of the projections relative to one another. Tomosynthesis has many properties that make it suitable as a modality for screening, including good diagnostic performance, short examination time and low radiation dose, it is a strong competitor to the current gold standard breast screening modality, i.e. mammography. At the same time, theoretical advantages have not yet been shown to translate into clinical advantage or even equivalence to standard mammography.

Metanalysis by Lei et al concluded: “Digital breast tomosynthesis has high sensitivity and specificity in breast diagnosis.• DBT appears to have superior diagnostic accuracy relative to digital mammography. • DBT images were captured at a lower dose than 2D images. • DBT displays abnormal features of lesions more clearly than DM. • Digital breast tomosynthesis could become the first choice for assessing breast lesions.”

In a statement in November 2014, while calling for more studies, the American College of radiology said:: To be clear: tomosynthesis is no longer investigational. Tomosynthesis has been shown to improve key screening parameters compared to digital mammography. “.

Yoo JY, Chung MJ, Choi B, Jung HN, Koo JH, Bae YA, Jeon K, Byun HS, Lee KS. Digital tomosynthesis for PNS evaluation: comparisons of patient exposure and image quality with plain radiography. Korean J Radiol. 2012 Mar;13(2):136-43. Epub 2012 Mar 7.

Tingberg A X-ray tomosynthesis: a review of its use for breast and chest imaging. Radiat Prot Dosimetry. 2010 Apr-May;139(1-3):100-7

ACR Statement on Breast Tomosynthesis, November 24, 2014. http://www.acr.org/About-Us/Media-Center/Position-Statements/Position-Statements-Folder/20141124-ACR-Statement-on-Breast-Tomosynthesis

Lei J, Yang P, Zhang L, Wang Y, Yang K.Diagnostic accuracy of digital breast tomosynthesis versus digital mammography for benign and malignant lesions in breasts: a meta-analysis. Eur Radiol. 2014 Mar;24(3):595-602.

Read the Layperson version here.

Scintimammography – pro

M Levin, MD — Thu, 23 Aug 2012 21:01:48 +0000

Scintimammography is independent of tissue density is a functional imaging technique. As such it has appea for dignostic use but it remains investigtional even for this application. It is not established for screening, or, as in this case, surveillance. It also ahs a potnetial use an adjunct to mammography.
Clinical studies have not clearly demonstrated the ability of scintimammography to differentiate between benign and malignant breast lesions, or for detecting and staging axillary lymph node metastases in patients with known breast cancer, improves net health outcomes. As an adjunctive diagnostic test after mammography, the sensitivity and corresponding negative predictive value of scintimammography have not been proven high enough to influence treatment decisions.
O’Connor MK, Phillips SW, Hruska CB et al. Molecular Breast Imaging: Advantages and Limitations of a Scintimammographic Technique in Patients with Small Breast Tumors. Breast J. 2007 Jan-Feb; 13(1):3-11.
Brem RF, Petrovitch I, Rapelyea JA et al. Breast-specific gamma imaging with 99mTc-Sestamibi and magnetic resonance imaging in the diagnosis of breast cancer-a comparative study. Breast J 2007 Sep-Oct; 13(5):465-9.
Brem RF, Fishman M, Rapelyea JA. Detection of ductal carcinoma in situ with mammography, breast-specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol. 2007 Aug; 14(8):945-50.
Brem RF, Floerke AC, Rapelyea JA et al. Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer. Radiology. 2008 Jun;247(3):651-7.
Zhou M, Johnson N, Blanchard D et al. Real-world application of breast-specific gamma imaging, initial experience at a community breast center and its potential impact on clinical care. Am J Surg. 2008 May;195(5):631-5;discussion 635.
ECRI Institute. Breast-specific Gamma Imaging for Diagnosis and Screening of Breast Cancer. Plymouth Meeting (PA): ECRI Institute; 2010 January 18. 7p. [ECRI hotline response]. Also available: http://www.ecri.org.

PET for breast cancer restaging – pro

M Levin, MD — Thu, 23 Aug 2012 20:56:39 +0000

18F-fluorodeoxyglucose (FDG) PET is increasingly used in restaging advanced or recurrent breast cancer and in monitoring response to therapy and has received approval for Medicare re-imbursement for these clinical indications. CMS covers PET for breast cancer staging except axillary staging. It covers FDG PET as an adjunct to standard imaging modalities for staging patients with distant metastasis, restaging patients with locoregional recurrence or metastases and monitoring tumor response to treatment for locally advanced and metastatic breast cancer when a change in therapy is contemplated.

There are few reports in the literature comparing PET with conventional imaging methods for breast cancer staging or restaging. The guidelines that support its use are mostly for staging or an adjunct modality). NICE says: “Positron emission tomography fused with computed tomography (PET-CT) should only be used to make a new diagnosis of metastases for patients with breast cancer whose imaging is suspicious but not diagnostic of metastatic disease. NCCN does not specifically address PET for restaging(BINV-17). NCCN accepts PET for initial staging of patients with locally advanced or metastatic breast cancer when conventional staging studies (e.g., CT or bone scan) are equivocal or suspicious or for follow-up or surveillance patients with breast cancer when conventional studies (e.g., CT or bone scan) are equivocal or suspicious. This is a Category B recommendation. A review (Rosen et al) says: “FDG PET and PET/CT have been shown to be particularly useful in the restaging of breast cancer, in evaluation of response to therapy, and as a problem-solving method when results of conventional imaging are equivocal. In these situations, FDG PET often demonstrates locoregional or unsuspected distant disease that affects management. PET has demonstrated a particular capability for evaluation of chemotherapy response in both patients with locally advanced breast carcinoma and those with metastatic disease.” Tateishi et al (2008) described how PET can be used to also monitor bone disease on therapy.

In the United States, current NCCN guidelines recommend the systematic use of 18F-FDG PET or PET/CT in breast cancer staging but state that “18F-FDG PET/CT may be helpful in identifying unsuspected regional nodal disease or distant metastases in LABC when used in addition to standard imaging studies”. In summary, the use of PET to restage on therapy should be limited to when other modalities are equivocal.

For monitoring: NCCN, Breast Cancer BINV-S 1, 2021

NCCN, Breast Cancer 2020

D. Groheux et al, 8F-FDG PET/CT for Staging and Restaging of Breast Cancer Nucl Med February 1, 2016 vol. 57 no. Supplement 1 17S-26S

S, Kim SB, Ahn JH, et al. 18 F-fluorodeoxyglucose uptake predicts pathological complete response after neoadjuvant chemotherapy for breast cancer: a retrospective cohort study. J SurgOncol. 2013;107(2):180-187.

Eric L. Rosen FDG PET, PET/CT, and Breast Cancer Imaging 1 October 2007 RadioGraphics, 27, S215-S229.

National Collaborating Centre for Cancer. Advanced breast cancer: diagnosis and treatment. London (UK): National Institute for Health and Clinical Excellence (NICE); 2009 Feb. 25 p. (NICE clinical guideline; no. 81).

David Mankoff Imaging in breast cancer – breast cancer imaging revisited, Breast Cancer Research 2005, 7:276-278

Benard F, Turcotte E: Imaging breast cancer with single photon computed tomography and positron emission tomography. Breast Cancer Res 2005, 7:153-162.

Bender H, Kirst J, Palmedo H, et al. Value of 18Fluoro-deoxyglucose positron remission tomography in the staging of recurrent breast carcinoma. Anticanc Res. 1997;17:1687-1692.

P VEIT-HAIBACH et al, FDG-PET/CT in restaging of patients with recurrent breast cancer: possible impact on staging and therapy ESMO (European Society of Medical Oncology). Clinical recommendations for diagnosis, treatment and follow-up of locally recurrent or metastatic breast cancer, 2005. Available from: http://www.esmo.org

Tateishi U, Gamez C, Dawood S, Yeung HWD, Cristofanilli M, Macapinlac HA. Bone metastases in patients with metastatic breast cancer: morphologic and metabolic monitoring of response to systemic therapy with integrated PET/CT. Radiology 2008; 247(1): 189–196.

MRI guided breast biopsy – pro

M Levin, MD — Thu, 23 Aug 2012 20:52:14 +0000

The American College of Radiology (ACR) has established guidelines to help uniformly assess the criteria for performing stereotactically guided breast biopsy for each modality including MRI. The ACR recommends that lesion visualization and access, availability of the imaging modality, efficiency, safety, and the practitioner’s experience are all used to determine the best guidance technique.

The MRI-guided biopsy is more cost-effective compared to a surgical biopsy and costs less.It si less expensive nad has fewer complications. Less scarring has a cosmetic benefit but also reduces the chance that the scar could obscure underlying tissue on mammography. Recovery time is minimal. The diagnosis is often made faster because of better access to biopsy suites than operating rooms. On the other hand, MRI is not the modality of choice for biopsying lesions that can be easily identified by mammography or sonography.

Weiss CR, Nour SG, Lewin JS. MR-guided biopsy: a review of current techniques and applications. J Magn Reson Imaging. 2008;27:311-325.

Weiss CR, Nour SG, Lewin JS. MR-guided biopsy: a review of current techniques and applications. J Magn Reson Imaging. 2008;27:311-325.
Amended 2014 – http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/MRI_Breast.pdf

American College of Radiology. ACR Practice Guideline for the Performance of Stereotactically Guided Breast Interventional Procedures. 2009.

Han BK, Schnall MD, Orel SG, Rosen M. Outcome of MRI-guided breast biopsy. AJR Am J Roentgenol. 2008;191:1798-1804.

Elissa R. Priceemail, Magnetic Resonance Imaging–Guided Biopsy of the Breast: Fundamentals and Finer Points. MRI CLinics August 2013Volume 21, Issue 3, Pages 571–581

Preoperative MRI for Breast Cancer – pro

M Levin, MD — Fri, 03 Aug 2012 13:53:54 +0000

The use of MRI before breast surgery is increasing based on reports that show that MRI can detect previously unknown foci of breast cancer in a substantial number of women with a new diagnosis of breast cancer. However, some argue that MRI will increase the proportion of mastectomy because it will cause more extensive surgeries. Since breast conservation surgery combined with radiation therapy as major advantages with similarly low recurrence rates and equivalent mortality, an increase in the rate of mastectomy prompted by MRI findings would be a negative development. Since studies have shown equivalent outcomes for lumpectomy with radiation and mastectomy, the implied argument is that the MRI just cause more extensive surgeries and not improve the results. Even if some foci are missed, preoperative MRI would have little or no impact on rates of recurrence or death because of post-operative radiation. For this reason, MRI should not be used routinely in the workup of new breast cancers.

At this time the effectiveness of radiation in eradicating residual foci of disease as compared to its surgical removal, is not known. Detecting widespread disease can obviate inappropriate attempts at conservation. Knowledge of the extent of disease can help patients select the most appropriate treatment options. A staging MRI examination showing only a single cancer lesion may permit the patient to choose conservation therapy with a high degree of confidence that no macroscopic disease will be missed at surgery.

American Society of Brat Imaging does recommend MRI to aid the assessment for eligibility and response to neoadjuvant endocrine therapy or chemotherapy before, during, or after treatment. MRI can help identify those patients who are candidates for breast conservation, and assist in determining the extent of resection.

National Comprehensive Cancer Network, . Clinical practice guidelines in oncology. Genetic/familial high-risk assessment: breast and ovarian cancer. www.nccn.org/professionals/physician_gls/f_guidelines.asp. 2018

American Society of Brast Imaging, https://www.gfmer.ch/Guidelines/Breast_diseases/Breast_imaging.htm

Jiyon Lee, Elaine Tanaka, Peter R. Eby, Shouhao Zhou, Wei Wei, Christine Eppelheimer, and Vilert A. Loving, Preoperative Breast MRI: Surgeons’ Patient Selection Patterns and Potential Bias in Outcomes Analyses. American Journal of Roentgenology 2017 208:4, 923-932

Morrow M, Freedman G . A clinical oncology perspective on the use of breast MR. Magn Reson Imaging Clin N Am 2006; 14:363–378.

Schnall MS MR imaging of cancer extent: is there clinical relevance? Magn Reson Imaging Clin N Am 2006; 14:379–381

LOUIE ENRIQUEZ, MD Role of MRI in breast cancer management Cleveland Clinic Journal of Medicine September 2009 vol. 76 9 525-532

Read the Layperson version here.

Bone Scan Versus MRI for Bone Metastatases in Breast Cancer – pro

M Levin, MD — Sat, 23 Jun 2012 01:51:00 +0000

The time course to the appearance of clinically detected distant metastases of breast cancer is extremely long. It is common for metastases to manifest 10 years or more after the initial diagnosis of breast cancer. It is generally accepted that least invasive methods for evaluating suspected metastases should be employed. The few studies that compared MRI, PET and bne scan found them to be simlarly effective. Bone scan is preferred to MRI in this regard since it is less invasive, less expensive and images the entire skeleton. MRI or PET—CT can be considered for cases of abnormal radionuclide uptake that are not addressed by radiography.

T. Ueno Bone Imaging in Metastatic Breast Cancer
J. Clin. Oncol., July 15, 2004; 22(14): 2942 – 2953.

Colleen M Costelloe Imaging bone metastases in breast cancer: techniques and recommendations for diagnosis The Lancet Oncology, Volume 10, Issue 6, Pages 606 – 614

LOUIE ENRIQUEZ, MD Role of MRI in breast cancer management Cleveland Clinic Journal of Medicine September 2009 vol. 76 9 525-532

nccn.org, 2012

MRI to screen preoperatively for DCIS – pro

M Levin, MD — Wed, 20 Jun 2012 23:41:26 +0000

Most guidelines recommend breast MRI for screening in women with high-risk of developing breast cancer and to clarify diagnostic uncertainties after mammography and ultrasound. As use of MRI has increased, many other situations for which, MRI might be helpful came to the fore. Unfortunately, literature support for most of them, is lacking.

Currently, guidelines indicate MRI for screening of women at high risk based on family history or for clarifying diagnostic dilemmas that are unable to be clarified by mammography and ultrasound. Some physicians adopt the strategy of using MRI to decide between a mastectomy and lumpectomy, when DCIS is present. The reasoning is that if widespread DCIS is found, a mastectomy would be performed rather than a lumpectomy. This strategy has not been formally evaluated and is not recommended by guidelines. A clinical trial is ongoing: Breast MRI as a Preoperative Tool for DCIS, NCT00605982. The purpose of this study is to see how often MRI can find other areas of cancer in women with one area of breast cancer, and to determine how having the MRI test affects their treatment. The study also aims to follow women who enter the study over a 10-year period to determine how often the breast cancer comes back.

ACR says: ” Invasive carcinoma and ductal cardinoma in situ (DCIS) – Breast MRI may be useful to determine the extent of disease and the presence of multifocality and multicentricity in patients with invasive carcinoma and ductal carcinoma in situ (DCIS). MRI can detect occult disease up to 15% to 30% of the time in the breast containing the index malignancy. MRI determines the extent of disease more accurately than standard mammography and physical examination in many patients. It remains to be conclusively shown that this alters recurrence rates relative to modern surgery, radiation, and systemic therapy.”

REFERENCES:

Kuhl CK, Schrading S, Bieling HB, et al. MRI for diagnosis of pure ductal carcinoma in situ: A prospective observational study. Lancet. 2007;370(9586):485-492.

http://www.acr.org/SecondaryMainMenuCategories/quality_safety/guidelines/breast/MRI_Breast.pdf – 2008

Read the Layperson version here.