Role of positron emission mammography (PEM) for assessment of axillary lymph node status in patients with breast cancer

Transcription

1 Role of positron emission mammography (PEM) for assessment of axillary lymph node status in patients with breast cancer Poster No.: C-1260 Congress: ECR 2011 Type: Scientific Paper Authors: K. M. Kulkarni, D. Appelbaum, C. Sennett, Y. Pu, G. M. Newstead; Chicago, IL/US Keywords: Breast, Nuclear medicine conventional, Metastases DOI: /ecr2011/C-1260 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 21

2 Purpose #Can PEM improve treatment decisions in breast cancer pertaining to the staging of Axillary Lymph Node (ALN)? #Current morphology based tools for ALN staging include clinical examination, axillary ultrasound and breast MRI, but none of them assess functional status to replace the need for pathologic evaluation of the axillary nodes. #To introduce PEM as an additional dimension to our Standard of Care imaging modalities for breast cancer Images for this section: Page 2 of 21

3 Fig. 1: Concept of PEM: Molecular imaging has the advantage of not being dependent on capillary angiogenesis 18-Flurodeoxyglucose (FDG) can diffuse into the interstitial space and be taken up by the abnormal cancer cells. FDG is ideal because of the increase uptake in cancer cells, while normal cells release the sugar, reducing background tissue levels. Page 3 of 21

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5 Fig. 2: Uptake of FDG in an abnormal left axillary lymph node Page 5 of 21

6 Methods and Materials MATERIALS: IRB approved prospective study n=20 (mean age 58 yrs, range 46-82) Inclusion criteria: Diagnosis of breast cancer (19 IDC, 1 DCIS) Mean cancer size = 2.1 cm All patients underwent mammography, breast and axillary ultrasound, breast MRI and PEM Suspicious lymph nodes using standard ultrasound criteria, were evaluated with ultrasound guided core biopsy performed for tissue diagnosis Final ALN status was determined pathologically either with biopsy of suspicious node or sentinel lymph node biopsy METHODS: Patient fasting for 4-6 hours before the examination Fasting blood glucose level (< 150 mg/dl) Injection of 10 mci, 18-FDG in the foot or contralateral arm (avoid infiltrated dose uptake in axilla) PEM scan mins after the injection Baseline 90 second scan of injection site / arm (for quality control) 10 min each for bilateral CC and MLO views Additional bilateral axillary views, 10 min each Images for this section: Page 6 of 21

7 Fig. 1: -Principles of PET imaging -High density crystals in a parallel array with close proximity to the breast -Reiterative reconstructions to eliminate background noise -Fast timing collimation -High count rate Page 7 of 21

8 Fig. 2: Case 1: Left MLO, CC Mammogram 2.5 cm partially circumscribed mass in left lower inner quadrant with enlarged left axillary lymph node Page 8 of 21

9 Fig. 3: Case 1: PEM Left CC and MLO view demonstrating increased uptake in lower inner quadrant Page 9 of 21

10 Fig. 4: Case 1: PEM scan Left CC, MLO views, with PUV quantitative analysis Page 10 of 21

11 Fig. 5: Case 2: Axial MRI shows biopsy proven cancer in left breast Page 11 of 21

12 Fig. 6: Case 2: PEM Left MLO view shows biopsy proven cancer with increased uptake Page 12 of 21

13 Fig. 7: Case 2: PEM Left CC showing increased uptake in biopsy proven cancer Page 13 of 21

14 Fig. 8: Case 2: Enlarged left axillary lymph node on axial MRI Page 14 of 21

15 Fig. 9: Case 2: PEM left axillary view shows multiple enlarged left axillary lymph nodes Page 15 of 21

16 Fig. 10: Case 3: (extreme left image) Right MLO PEM scan shows intraductal carcinoma in the right breast with peritumoral extension (extreme right image)right axillary PEM view shows increased uptake in multiple positive right axillary lymph nodes Page 16 of 21

17 Results PEM studies were interpreted by consensus of two radiologists SUBJECTIVE ANALYSIS: ALN were visually assessed based on intensity of uptake, categorized as: (1) none, (2) minimal and (3) significant. If at least one lymph node demonstrated significant uptake on PEM, it was considered positive. Region of interest drawn of the area with increased uptake Background ROI drawn on area of normal glandular tissue. OBJECTIVE ANALYSIS: Contrast to noise ratio for each lesion and lesion to background ratio for each patient calculated. GOLD STANDARD: Final pathology at sentinel lymph node biopsy or axillary lymph node dissection Results calculated for PEM, MRI separately, #Sensitivity #Specificity #PPV (Positive Predictive Value) #NPV (Negative Predictive Value) Images for this section: Page 17 of 21

18 Fig. 1: Subjective Analysis by two radiologists Fig. 2: Comparing PEM and MRI vs. Gold standard pathology (path) Page 18 of 21

19 Fig. 3: Results of ALN status using PEM and MRI Page 19 of 21

20 Conclusion Preliminary study of 20 patients shows promising results for accurate lymph node assessment. PEM demonstrates 88% sensitivity with a negative predictive value of 91% in assessment of ALN status in patients with breast cancer. Data shows improved lesion detectability and decrease in background activity Images for this section: Fig. 1: Results of ALN status using PEM and MRI Page 20 of 21

21 References 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 2004;11: Berg WA, Weinberg IN, Narayanan D, Lobrano MB, Ross E, Amodei L, et al. High Resolution FDG Positron Emission Tomography with Compression ("Positron Emission Mammography") is Highly Accurate in Depicting Primary Breast Cancer. Breast J 2006;12(4): Personal Information Kirti M. Kulkarni, M.D Assistant Professor of Radiology Section of Breast and Abdominal Imaging University of Chicago Hospitals 5841 S. Maryland Ave, MC 2026 Chicago, IL USA kkulkarni@radiology.bsd.uchicago.edu tel: Page 21 of 21