TÍTULO The role of FUSION between MRI and PET-CT as preoperative staging in breast cancer Páramo M, Zalazar R, Elizalde A, Pina-Insausti L, Vigil C, Hernández M, Rodríguez-Fraile M Clínica Universidad de Navarra Pamplona, Spain
The authors have nothing to disclose This study was approved by the ethic committee at our institution
INTRODUCTION Staging of breast cancer - To assess the tumoral size - To analyze the presence of multifocal, multicentric and contralateral lesions - To evaluate axillary lymph nodes
Staging of breast cancer TECHNIQUES INTRODUCTION MORPHOLOGICAL FUNCTIONAL Mammography US CE-MRI 18F-FDG PET/CT
INTRODUCTION F U N C T I O N A L CE-MRI: Based on neoangiogenesis High Sensitivity (95-98%) Low/intermediate Specificity (40-95 %) 18F-FDG PET/CT: Based on glicidic metabolism Intermediate Sensitivity Intermediate/high Specificity Complete extension of the disease
CE-MRI 18F-FDG PET/CT NIVERSITAS STVDIORV INTRODUCTION SAME PATIENT (Images from different techniques are hardly comparable if the patient position is different) PRONE SUPINE
INTRODUCTION Recently a new software has been developed that allows the FUSION of images acquired by both techniques (TRUED, Siemens, Germany) FUSION images CE-MRI 18F-FDG PET/CT
OBJECTIVE To compare the sensitivity (SE) and specificity (SP) of preoperative MRI, PET-CT and FUSION images between both techniques. CE-MRI 18F-FDG PET/CT
Inclusion criteria - From November 2011 to August 2013, 31 consecutive patients with histologically proven breast cancer were included. - All of them underwent both preoperative MRI and PET-CT 18F-FDG PET/CT MATERIALS AND METHODS CE-MRI (Biograph mct64, True V, Siemens) (1.5T AERA, Siemens, Erlangen, Germany)
Inclusion criteria MATERIALS AND METHODS 31 RETROSPECTIVE STUDY 67 Breast lesions 40 BREAST CANCER (histologically proven) 27 BENIGN lesions (biopsy and/or follow-up)
Fusion Technique MATERIALS AND METHODS The FUSION technique is based on two main facts: 1) Both CE-MRI and 18F-FDG PET/CT are acquired with the patient in PRONE POSITION, using the same MRI breast array coil A 4 channel breast MRI coil is used in both techniques (Noras, Höchberg, Germany)
MATERIALS AND METHODS CE-MRI (1.5T Aera, Siemens, Erlangen, Germany) 18F-FDG PET/CT (Biograph mct64, True V, Siemens) - STIR (TR=5000 ms, TE=57.0 ms, TI=170 MS Flip angle=141, Voxel=1.1x1.1x4 mm) - FLASH 3D (TR=4.82 ms, TE=1.85 ms, Flip angle=10, Fat-Sat, Voxel=0.8x0.8x1.5 mm) - Injection of 0.1 mmol/kg of paramagnetic contrast (Gadovist, Bayer) - Dynamic T1w post-contrast study ( 5 acquisitions at a time resolution of 60s) - Subtraction images are obtained - 60 min after administration of 0.12 mci / kg of 18F-FDG. We acquire two series: 1) In SUPINE position 6 beds whole body acquisition: used for the complete study of the extension of the disease 2) In PRONE position 2 beds acquisition using the breast array coil: focused in both breasts and underarms
MATERIALS AND METHODS Both techniques with the same patient in PRONE POSITION CE-MRI 18F-FDG PET/CT FUSION IMAGES
Fusion Technique MATERIALS AND METHODS The FUSION technique is based on two main facts: 2) A dedicated software (TRUED, Siemens, Germany) in a workstation (Leonardo, Siemens, Germany) is needed to perform the FUSION of both images
Lecture MATERIALS AND METHOD CE-MRI images were evaluated by an expert breast radiologist with more than ten years of experience, blinded to the final diagnosis 18F-FDG PET/CT images were evaluated by an expert nuclear medicine doctor, blinded to the final diagnosis FUSION images were evaluated RETROSPECTIVELY by consensus of: two expert breast radiologists and two nuclear medicine doctors
Analysis MATERIALS AND METHOD The correlation of images between MRI and PET/CT was evaluated and classified by consensus in: EXCELLENT: full coincidence ACCEPTABLE: <10 mm displacement POOR: 10 mm displacement All lesions were classified as positive (malignant) or negative (benign) for each technique and compared with the gold standard (surgery or follow-up) CE-MRI: BI-RADS 3, 4 and 5 were considered malignant (positive) PET/CT: morphologycal and visual criteria were used to classify benign/malignant. The SUV value was not considered
Analysis MATERIALS AND METHOD Statistical differences in SE and SP of the different imaging techniques were calculated using PEPI software (4.04 JH Abramson & PM Gahlinger)
RESULTS A.- Descriptive Main characteristics of women and tumours Mean age: 52.6 years old (35-81)
A.- Descriptive RESULTS Quality evaluation of fusion images EXCELLENT Full coincidence ACCEPTABLE < 10 mm displacement POOR 10 mm displacement 12 women (39 %) 16 women (52 %) 3 women (9 %)
B.- Analytical SENSITIVITY (%) RESULTS Table 1. Evaluation of sensitivity and specificity of each technique SPECIFICITY (%) CE-MRI 97.5 11.1 18F-FDG PET/CT 92.5 85.2 FUSION 95 96.3
RESULTS B.- Analytical Table 2. Comparison of SE and SP between CE-MRI and FUSION CE-MRI FUSION SENSITIVITY (%) 97.5 95 ns SPECIFICITY (%) 11.1 96.3 p < 0.05 Table 3. Comparison of SE and SP between PET/CT and FUSION PET/CT FUSION SENSITIVITY (%) 92.5 95 ns SPECIFICITY (%) 85.2 96.3 ns
CASES CE-MRI FUSION IMAGES 18F-FDG PET/CT
Case 1 CASES 45 y/o woman with BI-RADS 5 lesion in the right breast: IDC CE-MRI Extensive mass enhancement was seen in the right breast, highly suspicious of breast cancer 18F-FDG PET/CT Heterogeneous 18F-FDG uptake in the right breast was seen, suspicious of malignancy
Case Case 1 1 Case 1 CASES FUSION images confirmed the suspicion of breast malignancy In this case the FUSION between the images was excellent
Case Case 1 Case 1 1 cont. CASES - 18F-FDG PET/CT detected suspicious hepatic lesions (black arrow) Biopsy: breast cancer metastases
Case Case 2 2 Case 2 CASES 51 y/o woman with BI-RADS 5 lesion in the right breast: IDC RIGHT BREAST FUSION images confirmed the suspicion of breast malignancy In this case the FUSION between the images was excellent
Case Case 2 Case 2 2 cont. CASES LEFT BREAST - 18F-FDG PET/CT showed two suspicious deposits in the contralateral breast - On FUSION images, those foci of 18F-FDG uptake were matched with two areas of rim enhancement -These uptakes were in relation with inflammatory changes surrounding cysts, clearly diagnosed on CE-MRI as benign process and confirmed by fine needle aspiration (false positive of 18F-FDG PET/CT )
Case Case 3 3 Case 3 CASES 60 y/o woman with BI-RADS 5 lesion in the left breast: IDC LEFT BREAST - 18F-FDG PET/CT showed an heterogeneous 18F-FDG uptake - CE-MRI detected an extensive non-mass enhancement, highly suspicious - FUSION images confirmed the concern of breast malignancy. FUSION between both images was poor (> 10 mm displacement). Nevertheless the interpretation was quite easy
Case Case 3 Case 3 3 cont. CASES LEFT BREAST - 18F-FDG PET/CT did not inform any additional suspicious uptakes - CE-MRI detected an additional, non-mass enhancement located in the upper external quadrant of the same breast, suspicious of malignancy (white arrow) - FUSION images showed a subtle deposit on the non-mass enhancement (red arrow). - Biopsy: multicentric IDC (false negative of 18F-FDG PET/CT )
Case Case 1 1 Case 4 CASES 48 y/o woman with BI-RADS 5 lesion in the left breast: IDC - In this particular case FUSION images were useful to evaluate an additional suspicious lesion detected by CE-MRI (white arrow) as negative-benign lesion (green arrow). False positive of CE-MRI
Case Case 3 4 LIMITATIONS CASES Retrospective Small number of cases Probably benign lesions (BIRADS-3) were considered positive on CE-MRI
CONCLUSIONS 1 The FUSION of images between CE-MRI and 18F-FDG PET/CT is a feasible technique 2 The FUSION of images increases significantly the SPECIFICITY of preoperative CE-MRI (SP: 11.1% vs 96.3%; p<0.05) without decreasing the sensitivity (SE: 97.5% vs 95%; ns)
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MARÍA PÁRAMO ALFARO mparamo@unav.es