THE NEWEST TECHNIQUES FOR BREAST IMAGING

2nd annual San Antonio breast cancer symposium review

january 28, 2012

Sponsored By:

THE NEWEST TECHNIQUES FOR BREAST IMAGINGARE THERE ANY KEEPERS ?

MAXINE JOCHELSON MDMSKCC Breast Imaging Tools TodayMammography (X-Ray)

Purpose: Primary Screening

Advantages: inexpensive, widely available ,proven to reduce Mortality

Disadvantages: low sensitivity with dense breast tissue,

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Ultrasound

Purpose: Evaluation of mammographic findings and masses. biopsy. ?screening

Advantages: no radiation, inexpensive Disadvantages: time consuming, operator dependent, sub-optimal detection of DCIS and calcs. Low positive predictive value

Breast MRI

Purpose: screening, determine extent of known cancer, f/uAdvantages: extremely sensitive no radiation, physiology +anatomy Disadvantages: expense, lacks specificity, claustrophobia, no implanted metal, not universally available

EVOLUTION OF STANDARD TECHNOLOGYDIGITAL BREAST TOMOSYNTHESIS (DBT)

CONTRAST ENHANCED MAMMOGRAPHY (CESM)

ULTRASOUND WITH ELASTOGRAPHY

ULTRASOUND WITH MICROBUBBLES

MRI WITH DIFFUSION WEIGHTED IMAGING

MRI WITH SPECTROSCOPY

NEW PLATFORMS: NUCLEAR IMAGING AND COMPUTERIZED TOMOGRAPHYIMAGING WITH MIBI (MBI)(BSGI)

POSITRON EMISSION MAMMOGRAPHY (PEM) INCLUDING NEW TRACERS

CT AND PET/CT OF THE BREAST

Digital mammography (FFDM)Lower radiation doseDisplay is different-can manipulate imagesImproved performance in dense breasts: sensitivity increased from 55-70%*No increase in overall detectionServes as a template for DBT and cedm

Pisano ED NEJM 2005 TOMOSYNTHESISFDA APPROVED TO BE PERFORMED WITH FFDMMultiple projections of compressed breast with moveable X-Ray source

Image slices reconstructed in plane parallel to detector

Strips away superimposed tissue

2x Radiation of FFDM

IMPROVED LESION CONSPICUITYPRIMARILY WITH SOFT TISSUE LESIONS CHARACTERIZATION OF LESIONSMARGIN FEATURE ANALYSISDETECTION OF ADDITIONAL FINDINGSMAY SHOW NORMAL PARENCHYMA WHEN A MASS IS SUSPECTED

IMPROVED SENSITIVITY AND SPECIFICITY@ components of cancers: soft tissue and calcs9

DECREASED NUMBER OF CALLBACKSPOPLACK: 40% DECREASE 99 WOMEN: AJR 2007SMITH: 39% DECREASE: LNCS 2008KOPANS: 41% (7.8% TO 4.6%) 3015 SINGLE VIEW TOMO EXAMS WITH 2 VIEW FFDM: RSNA 2009

THIS IS AN ADVANTAGE IF USED FOR SCREENING W/O FFDM

DBT COMPARED TO SPOT FILMS67 MASSES: 30 CANCERS, 37 BENIGNMASS CHARACTERIZATION EQUIVALENT BETWEEN 2 MODALITIESDBT SHOWED 7 ADDITONAL CANCERSAND 5 ADDITIONAL FALSE +S

Noroozian et al Radiology Jan 2012 ADDITIONAL RADIATION DECREASING THE ADDITIONAL VIEWS OBTAINED ON CALL BACKS MAY PARTIALLY NEGATE THE ADDITIONAL RADIATION FROM TOMOSYNTHESIS. (10% CALLBACK RATE)

ALL STILL FALL WITHIN MQSA GUIDELINESDBT LMLO

Source: Oncological Institute of Veneto, Padua, ItalyCaution Investigational Device Limited by United States Law to Investigational Use

DBT Clinical ExamplesNotes:Lobular Carcinoma seen by DBT

Source: Oncological Institute of Veneto, Padua, Italy

Caution Investigational Device Limited by United States Law to Investigational Use

DBT Clinical ExamplesImages courtesy of Dr. Hak Hee KimAsan Medical Center, Seoul, KoreaNotes:Equivocal lesion that is a true negative with DBT.

Source:Source: ASAN Medical Center Seoul Korea

MICROCALCIFICATIONS NOT AS EASILY ASSESSED W/DBT DUE TO THIN (1MM) SLICES AND BLURRING OF TOMOGRAPHYPROBABLY EQUIVALENT TO FFDM:

MICROCALCIFICATIONS SENSITIVITY HIGHER FOR FFDM 84% VS 75%SPECIFICITY HIGHER FOR FFDM 71% VS 64%FFDM DETECTED MORE CANCERS WITH CALCIFICATIONS DIFFERENCES NOT SIGNIFICANT

Spangler et al AJR Feb 2011

MICROCALCIFICATIONS103 PATIENTS: FFDM VS DBTALL HAD KNOWN SUSPICIOUS CALCS95% DBT WAS EQUIVALENT OR BETTERDBT LESIONS 18MM VS 16MM FFDM

Destounis et al ARRS May 2011FREE RESPONSE ROC PARADIGM125 EXAMS RETROSPECTIVELY EVALUATEDFFDM ALONE OR WITH TOMOSYNTHESISCOMBINATION SHOWED MORE TRUE + ABNORMALITIES ALSO MORE FALSE+ BUT THE GOOD OUTWEIGHED THE BAD16% PERFORMANCE IMPROVEMENT (ON AVERAGE)

GUR ETAL AJR March 2011 ADDITIONAL ISSUES EVALUATES ONLY ANATOMYAMOUNT OF TIME NEEDED FOR INTERPRETATION (ROLE FOR CAD)LIMITED TO NO REIMBURSEMENTWHEN TO USE: ALL SCREENS, HIGH RISK OR WORK/UP AFTER SCREEN?NEED FOR FFDMCONCLUSIONSPROMISING BUT NOT READY FOR CLINICAL ROLE OUT-BUT IT IS ADVERTISED TO THE PUBLICTHEY ARE BEING PURCHASED ~90-110 UNITS (10,000 MAMMO UNITS)ONCE 1 PLACE GETS ONE-EVERYONE WANTS ONE

3-D Mammograms: Ultimate Benefits Unknown.The Boston Globe (8/15, Carmichael) reports on the 3-dimensional mammography machines, which were approved by the Food and Drug Administration in February. The technology is promoted as being more accurate than 2-d, because 3-d is better at imaging formations of breast cancer cells such as "spicules, or thin, spidery tentacles emerging from the center of a tumor" which are a mark of malignancy. However, as the Globe points out, "the most meaningful data" on any changes on morbidity and mortality "won't be available for decades DUAL ENERGY CONTRAST ENHANCED DIGITAL MAMMOGRAPHY (CEDM)ADDING PHYSIOLOGY TO ANATOMY

FDA APPROVED AS CESM 11/2011 BACKGROUND MRI is useful in breast imaging due to its ability to image blood flow

Could contrast enhancement using digital mammographic technology approach the usefulness of MRI?

MATERIALS Digital mammography unit adapted to perform low & high energy exposures: iodine image

IODINATED CONTRAST-SAME AS CT

WHAT ARE THE RISKS ? Iodinated contrast administration

Radiation: 20% > than screening mammo (equivalent to 1 extra image)EARLY DATA142 LESIONS IN 120 PTS UNILATERAL MAMMO+CEDM VS MAMMO ALONESENSITIVITY 93% VS 78% W/O CHANGE IN SPECIFICITY

Dromain Eur Radiol 2011 NEXT STEPSCONFIRM FEASIBILITY OF BILATERAL CEDM

TO COMPARE CEDM and MRIFor ability to detect breast cancerTo define the extent of tumorFor false positive rates

Jochelson et al RSNA 2010

DETECTION OF INDEX LESION

CEDM25/26 = 96%MRI25/26 = 96%MAMMO 22/26 = 85%INDEX LESIONS DETECTED BY CEDM Lesion size: range, 5 to 50 mm (MEDIAN 12)

MRI vs CEDMMRICEDM

INDEX CANCER:true +2525false -11ADDITIONAL IPSI CANCER:true +75false +40false 02CONTRALATERAL CANCER:true +00false +30 MRI vs CEDMMRICEDM

INDEX CANCER:true +2525false -11ADDITIONAL IPSI CANCER:true +75false +40false 02CONTRALATERAL CANCER:true +00false +30 MRI vs CEDMMRICEDM

INDEX CANCER:true +2525false -11ADDITIONAL IPSI CANCER:true +75false +40false 02CONTRALATERAL CANCER:true +00false +30 MRI vs CEDMMRICEDM

INDEX CANCER:true +2525false -11ADDITIONAL IPSI CANCER:true +75false +40false 02CONTRALATERAL CANCER:true +00false +30CEDM vs MRI sensitivity of lesion detectionOf all known sites of cancer in the breasts, those identified by each technology were:

CEDM30/33 = 91%

MRI32/33 = 97%CEDM VS MRIlesion specificityOf all enhancing lesions, cancers were:

CEDM30/30 = 100%

MRI30/37 = 81%

35289432 CEDM right and left38

35289432 right and leftT1 fat suppressed post contrast MRI

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35288678 left cedm and MIP

40 CONCLUSIONS CEDM matches MRI in its ability to detect PRIMARY CANCER within THE breast (KNOWING THERE IS A CANCER)

The issue of screening is not addressed

IT DETECTS FEWER LESIONS WITHIN THE BREAST-CLINICAL IMPORTANCE TO BE DETERMINED

CEDM detects malignant disease in the breast with fewer false positives than MRI

CASE FOR ULTRASOUNDFor further evaluation of mammo and clinical findingsFor core biopsies SCREENINGLow sensitivity of mammo particularly in dense breastsNo radiationInexpensiveWidely availablePROBLEM WITH ULTRASOUND.4% PICK UP OF ADDITIONAL LESIONSLots of additional biopsies90% OF BIOPSIES ARE BENIGNLARGE NUMBER OF SHORT INTERVAL FOLLOW-UP EXAMS

Radiologists annuityULTRASOUND CONTRAST AGENTMicrobubbles of gas within lipid microspheresOscillate and emit signals detected by u/s probeDiffer from iodine- do not diffuse outside the vesselImproves vessel visualization c/w DopplerNot easy to useMICROBUBBLESEarly studies show improved sensitivity of up to 100%Specificities 5.6-100% (increased small non-relevant-vessel detection

Kedar Radiol 1996Moon Radiol 2000Alamo Eur Radiol 2001CONTRAST-ENHANCED BREAST ULTRASONOGRAPHY (CEUS)Liu et al: J Ultrasound Med 2009:104 patients with breast masses: CEUS correlated with histologic features

Sever et al : AJR 2011: Sentinel lymph nodes may be identified and localized with microbubbles before surgery

ElastographyStatic (Compressive): Manual compressionShear WaveCancers harder and less compressible

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ResultsAccuracy of GS US vs Elastography plus GS US (Combined US) No statistically significant difference between greyscale US alone and combined US (all confidence intervals for each estimate overlapped)

Bar chart instead?50NUCLEAR BREAST IMAGINGPEM AND MIBI ADVANTAGESPHYSIOLOGY ASSESSMENT METHOD TO DETECT CANCER THAT IS INDEPENDENT OF BREAST DENSITY METHOD TO DETECT BREAST CANCER THAT IS INDEPENDENT OF HORMONE STATUS (PEM)

This add is from the 90s53NEW TECHNOLOGY NOW AVAILABLE

BREAST IMAGING WITH MIBI BREASTS ARE POSITIONED AS THEY ARE WITH MAMMOGRAPHY

MILD COMPRESSION

HIGH RESOLUTION

TECHNIQUE BETWEEN DAYS 2 AND 14 OF CYCLE

740-1110 MBq

WAIT A MINUTE

IMAGES ACQUIRED FOR 5-10 MINUTES EACH

AXILLARY VIEWS SEPARATEMOLECULAR BREAST IMAGING (MBI) CZT TECHNOLOGYSENSITIVITY 91% OVERALL69% FOR LESIONS < 5MM88% IDC ALL SIZES79% ILC ALL SIZES89% DCIS ALL SIZES

Hruska etal 2008 Am J of Surgery

MBI VS MAMMOGRAPHY11 CANCERS IN 936 PATIENTS WITH DENSE BREASTS AND AT LEAST 1 ADDITIONAL RISK FACTORMAMMO DETECTED 3CZT DETECTED 91 DETECTED BY NEITHERSPECIFICITY IS EQUIVALENT

RHODES ET AL RADIOL JAN 2011MBI confirms diagnosisAge: A 61-year old patient

MBI: Multiple foci of increased 99mTc-MIBI uptake corresponding to the MRI findings.Suggestive multicentric multifocal disease.In the left central and superior outer quadrant

Mammography: Detected 2cm lesion in the left superior outer quadrantUltrasound:left 1:00 position, 2x1.6 cmleft 2:00 position 0.7x0.9cm BSGI 146 PATIENTS WITH 167 LESIONSSENSITIVITY 96.4% (DCIS AND IDC)SENSITIVITY 88.9% SUBCENTIMETER SPECIFICITY 59.5%MEDIAN SIZE 15MM

ADDITIONAL CANCERS IN 7.2% OF PATIENTS NOT SEEN ON MAMMO OR ULTRASOUND

Brem et al RADIOLOGY 2008

STAGING BREAST CANCERADDITIONAL LESIONS IN 18/82 OF PATIENTS WITH BREAST CANCER9% ADDITIONAL CANCERS22% CHANGE IN SURGICAL MANAGEMENT

Killelea et al Am J Surg 2009

REMEMBER-SPECIFICITY NOT MUCH BETTER THAN MRI62OCCULT FOCI ON MAMMO159 PATIENTS46 (29%) ADDITIONAL LESIONS14(9%) MALIGNANT3% WERE IN THE CONTRALATERAL BREAST

Brem et al Acad Radiol 2010

BSGI

BSGI65Left Side: When in the prone breast pendent position, the breast falls about 2 to 3 inches from the face of the detector due to the presence of the shoulder, table, etc. This distance results in spatial resolution losses.

Right side: If we could shrink the detector and place it in direct contact with the breast, we can significantly improve the spatial resolution of the study.

* Bringing the breast closer to the detector is paramount for optimal imaging.

BSGI66POSITRON EMISSION MAMMOGRAPHYPEM WHOLE BODY PET EARLY STUDIES EVALUATED USEFULNESS IN THE BREASTSENSITIVITY LIMITED OVERALL ~39%COLLIMATOR TOO FAR FROM THE BREASTS69High (1.5 2.0 mm) spatial resolution 4-10 minute scan time Compact, portable, easy to useHigh Value 3-D tomographic PET imagesGentle Immobilization vs. CompressionPEM

HOW IS IT DONEPATIENT MUST FAST 4-6 HOURSAFTER INJECTION REST FOR 1 HOUREACH IMAGE TAKES 10 MINUTESCAN ALSO BE PERFORMED AFTER WHOLE BODY PET/CT WITHOUT ADDITIONAL TRACERWB PET and PEM

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Images Courtesy Dr. Kathy Schilling, MDBoca Raton Community HospitalMalignant Index Lesions(n=167)PEMBreast MRIDCIS (n=30)90% (27/30)83% (25/30)Invasive Cancer (n=137) 93% (128/137) 95% (130/137) T1a (n=4) 100% (4/4) 75% (3/4) T1b (n=21) 86% (18/21)91% (19/21) T1c (n=57) 93% (53/57)95% (54/57) T2 (n=52) 96% (50/52)98% (51/52) T3 (n=3) 100% (3/3) 100%(3/3)72 Sensitivity & Small Lesion Detection Schilling, K, Narayanan MS, Kalinyak JE. Multimodality Effect of Breast Density, Menopausal Status and Hormone Use in High Resolution Positron Emission Mammography. Presented at the 94th Annual Meeting of the Radiological Society of North America, November 2008the sensitivity of the lesions detection with PEM was compared to the imaging gold standard of breast MRI This was a prospective single site trial of 208 patients at Boca Raton Community Hospital. As highlighted in red, PEM had a trend of increased sensitivity for DCIS when compared to breast MRI.

PEM VS MRI388 PTS WITH NEWLY DIAGNOSED BREAST CA

82(21%) ADDITIONAL CANCERS: SHOWED BY BOTH EXAMS IN 28(34%)MRI ALONE 14(17%)PEM ALONE 7 (8.5%)MRI DETECTED 61 (53%) ADDITIONAL LESIONS VS 47 (41%) BY PEM p=.043PPV OF MRI 53% VS PEM 66% p=.01656(14%) BREASTS REQUIRED MASTECTOMY:MRI DEPICTED 40(71%) VS PEM 20(36%)

PEM VS MRIPEM AND MRI HAD COMPARABLE BREAST LEVEL SENSITIVITY WHILE MRI HAD BETTER LESION LEVEL SENSITIVITYPEM MORE SPECIFIC AT BOTH PATIENT AND LESION LEVELS89(23%) REQUIRED MORE SURGERY:MRI FOUND 61(69%) VS PEM 41(46%)

BERG ET AL RADIOLOGY JAN 2011PEM VS MRI CONTRALATERAL BREAST367 WOMEN WITH BREAST CA15(4.1%) W/ CONTRALATERAL CAMRI DETECTED 14(93%)PEM DETECTED3(20%)PROSPECTIVELY-11 WERE ACTUALLY VISIBLE

Berg et al AJR 2012PEM Compared to Mammography

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NippleIndex LesionLymph NodeSecondary malignancy17Images Courtesy Dr. Kathy Schilling, MDBoca Raton Community HospitalNOT ALWAYS ABLE TO SEE BACK TO THE CHEST WALL WITH PEMPathological Confirmation of IDC and DCIS

77History:40 year old dense-breasted female presenting with palpable abnormality on right breast.

Findings:Ultrasound-guided biopsy showed expected IDC from mammogram but with unexpected DCIS intertwined in lesion. MRI and PEM found expected IDC lesion and greater than expected extensive DCIS.Images courtesy James Rogers, MD, Swedish Cancer Center, Seattle, WAThis slide demonstrates the good correlation PEM has with both pathology and MRI. What is PEM image cannot show is how easy it is to learn how to interpret the PEM images, however, the results of this type of study was presented by Dr. Berg at RSNA. In addition, what is not seen is the fact that it takes on average only one fourth of the time to interpret the PEM images compared to the time it takes to review the 1700 slices of a breast MRI.

Patient is upright

Pillow for patient comfort

Easier than MRI for patients with severe kyphosis or back problems

No claustrophobiaPEM-Guided Biopsy78

As seen on this slide, the advantages of this approach are numerous:First, the patient is upright and comfortable, particularly important for the older, kyphotic patientNo worry of procedure cancellation due to claustrophobia,No worry of allergic responsesNo weight limitationFinally, this procedure is available for all patients, including those with metal clips, pacemakers or hip replacements

Also note the comfortable position for the physician doing the biopsy.

Remember, all targeting is being accomplished using only PET guidance---a real technology breakthrough.

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First FDA Cleared & Commercially Available Breast PET-Guided BiopsyClearly Visualize the LesionPEM-Guided Biopsy Target Using 3-D PEM ImagesConfirm RemovalConfirmation with Specimen Scan79The biopsy process is a simple 4 step process.Image the breast and target the lesionCheck the alignment using a ge68 line sourceCheck the lesion for either removal or architectural alterationConfirm adequate sampling with a sample scan.

Thus, the patient never leaves your office with any question as to whether the biopsy sampling was successful.

79PEM VS MIBIBOTH EVALUATE PHYSIOLOGYBOTH DENSITY INDEPENDENTPEM NOT DEPENDENT ON HORMONE STATUS BSGI REQUIRES NO FASTING. NO REST PERIOD

ADDITIONAL ADVANTAGES FOR PEMPEM IS MORE SPECIFIC

CAN BE DONE AFTER WHOLE BODY SCAN WITH NO ADDITIONAL TRACER

CAN USE DIFFERENT TRACERS WHICH MAY IMPROVE SENSITIVITY (LOBULAR CANCERS), SPECIFICITY AND RESPONSE EVALUATION

Patient 2:

A

B FACBC PET CT FACBC PET/CT A. Axial FACBC PET, CT, and hybrid FACBC PET/CT images demonstrating high tumor-to-background FACBC uptake in a patient with invasive ductal carcinoma of the breast. B. Maximum intensity projection (MIP) FACBC PET image demonstrating visualization of the primary breast cancer and multiple ipsilateral lymph nodes. Liver in the right upper abdomen.MIP FACBC PET

RADIATION DOSES AND CANCER RISKS DEFINED AS LIFETIME ATTRIBUTABLE RISKSAnnual screening mammography: 20-25 cases/100,000BSGI:20-30 x mammo in 40yoPEM:23 x mammo in 40yoA single BSGI/PEM study associated with fatal radiation induced cancer risk higher than a lifetime of annual mammography in women 40-80 years

Hendricks, RE Radiology 2010

THANK HH84CANT USE RADIONUCLIDE BREAST IMAGING FOR SCREENINGCT AND PET/CTUC Davis Breast PET/CT

BREAST CTMORE COMFORTABLECAN NOT SEE THE POSTERIOR BREAST/AXILLARY TAIL RELIABLY69 WOMEN WITH BIRADS 4 OR 5 ON FILM SCREEN HAD CTCT FOUND 89% (BUT POSTERIOR LESIONS NOT INCLUDED)MASSES SEEN BETTER THAN MAMMO, CALCS NOT AS WELL

Lindfors: Radiology 2008

Pre and post contrast breast CT- John Boone89Contrast-enhanced Dedicated Breast CT- Boone et al.

49-yo woman, palpable mass in right upper outer quadrant. ( Dr Badawi)Invasive mammary carcinoma confirmed at biopsy.

Whole-body PET/CT

Dedicated breast PET/CTImages courtesy of SL Bowen

Department of RadiologyDepartment of Biomedical EngineeringDr Badawi91

Breast PET/CT gives Fully 3D Data Sets

92 IMPORTANT CONTROVERSY WHETHER OR NOT DETECTION OF ADDITIONAL MAMMOGRAPHICALLY OCCULT DISEASE DETECTED BY MRI (OR ANY OTHER IMAGING EXAM) ACTUALLY LEADS TO IMPROVED PATIENT CARE: DECREASE REEXCISION RATES, IMPROVED LOCAL CONTROL, IMPROVED SURVIVAL AFFECTS THE NEED FOR THESE NEW MODALITIESCONCLUSIONSDIGITAL MAMMOGRAPHY ADAPTATIONS SHOW PROMISE FOR IMPROVED SENSITIVITY-NEED A LOT MORE WORKMICROBUBBLES UNLIKELY TO BE PRACTICAL FOR REGULAR USEELASTOGRAPHY IS NOT THERE YETCONCLUSIONNUCLEAR BREAST IMAGING IS MORE SENSITIVE THAN MAMMOGRAPHY AND SIMILAR TO MRI. PEM SPECIFICITY IS BETTER THAN THE OTHER TESTSRADIATION DOSE IS A SIGNIFICANT DETERRANT TO SCREENINGCOULD CONSIDER FOR PREOP STAGING, PROBLEM SOLVING OR ASSESSMENT OF TREATMENT RESPONSE Thats all folks

PEM & 3-D IMAGING

98PEM generates 12 tomographic slices per view offering a 3-D perspective of the BreastWhy does 3-D imaging make a difference? At the core of our clinical strength is 3 dimensional PET technology. Our PEM scanner is a high-resolution PET scanner optimized for breast imaging and provides tomographic slices with 2 mm resolution images. Now why do tomographic slices matter? Tomographic slices provide a 3-D perspective of the disease state and enables physicians to make better decisions. I was recently talking to a breast surgeon and radiologist who were using PEM tomographic slices for pre-surgical planning and they put it best by explaining how important it was for them to better visualize the extent and location of the disease. This allowed them to improve surgical outcomes by being able to reduce positive margins. Ultimately, 3D imaging is impacting their ability to treat patients and optimize the course of treatment.

TECHNIQUE Omnipaque 350, 1.5ml/kg, power injector, 3ml/sec

Begin imaging 3 min post-injection

4 views completed in average 8 minutes (range, 6-10)

DOES NOT MATTER IN WHICH ORDER FILMS ARE TAKEN

Validation

Breast PET/CTDCE-MRIHistologyEDCFAB(A) Periareola (excised from histology sample)(B) Implant capsule(C) DCIS + intra-lymphatic(D) DCIS(E) DCIS(F) Normal benign

Specimen

Edcfabedcfab

Department of RadiologyDepartment of Biomedical Engineering100Functional Imaging Adds Clarity

101History: 46 year old with suspicious 1 cm mass overlying right pectoral muscle on screening mammogram.

Findings: Ultrasound-guided biopsy confirmed IDC at 12 oclock. PEM correlate was found as well as a second site suspicious for malignancy. MRI was performed and found known index IDC but no additional abnormality prospectively. Retrospective comparison to PEM showed the possible secondary site of centrally clumped enhancement. MRI-guided biopsy found DCIS.Images courtesy Marie Tartar, MD, Scripps Cancer Center, La Jolla, CAThis case highlights a couple of important aspects of PEM: First, this patient was a premenopausal women with relatively dense breasts. Note, PEM imaging was not affected. The 1 cm mass was seen on the mammogram is sitting on the pectoralis muscle. We frequently get asked about how well we can see posterior lesions and as you can see here, we have no problem. Both MRI and PEM identified the same posterior lesions, however, the central heterogenous region was interpreted as hormonal perturbation on MRI, that was until the radiologist reviewed the PEM image which clearly shows a central nodule of FDG uptake. Because PEM guided biopsy was not available at the time of this imaging, a second look MRI image with biopsy was central area on the MRI image was used to prove this region of FDG uptake was due to DCIS. Now, a radiologist would be able to use PEM, the imaging modality that was the first and best for identifying this cancer.

DBT Clinical Examples2D FFDMTomosynthesis SlicesCaution-Investigational Device Limited by United States Law to Investigational Use.

Images courtesy of Dr. Hak Hee KimAsan Medical Center, Seoul, Korea

STAGING BREAST CANCER138 PATIENTS15 (10.9%) HAD ADDITIONAL OCCULT DISEASE IN IPSILATERAL OR CONTRALATERAL BREASTS

Zhou er al Am J Surg 2009 n = 40 prospective single site study

PEM and mri sensitivity 92.3%

WB PET sensitivity 39%.

PEM not adversely affected by hormonal changes . .Schilling K. J NUCL MED MEETING ABSTRACTS 2007 COMPARED TO WHOLE BODY PET AND MRIPROSPECTIVE MULTICENTER TRIAL

94 women with known breast cancer. Readers were provided clinical histories and mammograms.

sensitivity 91%, specificity 93%, negative predictive value 88% and accuracy 92%.

PEM was able to identify 91% of DCIS preoperatively.

Berg et al- the breast journal 2006 CANCER DETECTION

History: 63 y/o postmenopausal woman with invasive lobular carcinoma right breast imaged with PEM& MRI preoperatively.

Findings: MRI: Identified 5 mm central left breast lesion. PEM: Showed13 mm irregular mass with increased FDG uptake medial right breast. No suspicious finding on the left breast. Pathology: Bilateral mastectomy: Low grade 14 mm invasive lobular carcinoma on the right & benign fibrocystic changes on the leftImaging a Suspicious MassRL

ILCLRFalse positive nodule** Schilling: High Resolution PEM: Utility in Pre-Surgical Planning for Breast Cancer Patients. SNM Meeting 2008 MRIPEM106B-033 This next slide is here to show an example of the specificity that PEM adds to breast imaging. PEM was not confused by the fibrocystic changes seen on the left breast by MRI.

PEM Valuable for Cancer Detection and Surgical Planning

prospective multicenter study: 44 patients with newly diagnosed breast cancer.

39 detected with pem.

19 : breast conservation surgery: correctly predicted 75% of patients with positive margins and 100% of patients with negative margins.

detected 4 of 5 ADDITIONAL incidental breast cancers, 3 not seen on other modalities.

Tafra et al Am J of Surg 20052nd annual San Antonio breast cancer symposium review

january 28, 2012

Sponsored By:

Chart195.293.333.336.248.849.191.290.5

GS aloneCombined US95.2%33.3%48.8%91.2%93.3%36.2%49.1%90.5%

Sheet1GS aloneCombined USColumn1Sensitivity95.293.32Specifivity33.336.22PPV48.849.13NPV91.290.55To resize chart data range, drag lower right corner of range.

BSGI

BSGI

BSGI

BSGI

*
Left Side: When in the prone breast pendent position, the breast falls about 2 to 3 inches from the face of the detector due to the presence of the shoulder, table, etc. This distance results in spatial resolution losses.

Right side: If we could shrink the detector and place it in direct contact with the breast, we can significantly improve the spatial resolution of the study.

* Bringing the breast closer to the detector is paramount for optimal imaging.
*