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Rapley M, Freitas V, Weinberg IN, Baldassi B, Poladyan H, Waterston M, Ghai S, Taeb S, Bubon O, Reznik A, Mulligan AM. Case report: Possible role of low-dose PEM for avoiding unneeded procedures associated with false-positive or equivocal breast MRI results. Front Oncol 2024; 14:1405404. [PMID: 39091907 PMCID: PMC11291220 DOI: 10.3389/fonc.2024.1405404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/05/2024] [Indexed: 08/04/2024] Open
Abstract
Contrast-enhanced breast magnetic resonance imaging (MRI) is currently recommended as a screening tool for high-risk women and has been advocated for women with radiologically dense breast tissue. While breast MRI is acknowledged for its high sensitivity (with an exception for lower-grade ductal carcinoma in situ (DCIS) where emerging techniques like diffusion-weighted imaging offer improvement), its limitations include sensitivity to hormonal changes and a relatively high false-positive rate, potentially leading to overdiagnosis, increased imaging uncertainty, and unnecessary biopsies. These factors can exacerbate patient anxiety and impose additional costs. Molecular imaging with breast-targeted Positron Emission Tomography (PET) has shown the capability to detect malignancy independent of breast density and hormonal changes. Furthermore, breast-targeted PET has shown higher specificity when compared with MRI. However, traditional PET technology is associated with high radiation dose, which can limit its widespread use particularly in repeated studies or for undiagnosed patients. In this case report, we present a clinical application of low-dose breast imaging utilizing a breast-targeted PET camera (Radialis PET imager, Radialis Inc). The case involves a 33-year-old female patient who had multiple enhanced lesions detected on breast MRI after surgical removal of a malignant phyllodes tumor from the right breast. A benign core biopsy was obtained from the largest lesion seen in the left breast. One month after the MRI, 18F-fluorodeoxyglucose (18F-FDG) PET imaging session was performed using the Radialis PET Imager. Although the Radialis PET Imager has proven high count sensitivity and the capability to detect breast lesions with low metabolic activity (at a dose similar to mammography), no areas of increased 18F-FDG uptake were visualized in this particular case. The patient underwent a right-sided nipple-sparing mastectomy and left-sided lumpectomy, with bilateral reconstruction. The excised left breast tissue was completely benign, as suggested by both core biopsy and the PET results. The case presented highlights a promising clinical application of low-dose breast-targeted PET imaging to mitigate the uncertainty associated with MRI while keeping radiation doses within the safe range typically used in X-ray mammography.
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Affiliation(s)
- Madeline Rapley
- Department of Physics, Lakehead University, Thunder Bay, ON, Canada
| | - Vivianne Freitas
- Temerty Faculty of Medicine, Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Sandeep Ghai
- Temerty Faculty of Medicine, Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Samira Taeb
- Department of Research, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Oleksandr Bubon
- Department of Physics, Lakehead University, Thunder Bay, ON, Canada
- Radialis Inc., Thunder Bay, ON, Canada
| | - Alla Reznik
- Department of Physics, Lakehead University, Thunder Bay, ON, Canada
- Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada
| | - Anna Marie Mulligan
- Laboratory Medicine Program, University Health Network – Toronto General Hospital Site, University of Toronto, Toronto, ON, Canada
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Patel MM, Adrada BE, Fowler AM, Rauch GM. Molecular Breast Imaging and Positron Emission Mammography. PET Clin 2023; 18:487-501. [PMID: 37258343 DOI: 10.1016/j.cpet.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
There is growing interest in application of functional imaging modalities for adjunct breast imaging due to their unique ability to evaluate molecular/pathophysiologic changes, not visible by standard anatomic breast imaging. This has led to increased use of nuclear medicine dedicated breast-specific single photon and coincidence imaging systems for multiple indications, such as supplemental screening, staging of newly diagnosed breast cancer, evaluation of response to neoadjuvant treatment, diagnosis of local disease recurrence in the breast, and problem solving. Studies show that these systems maybe especially useful for specific subsets of patients, not well served by available anatomic breast imaging modalities.
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Affiliation(s)
- Miral M Patel
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, CPB5.3208, Houston, TX 77030, USA.
| | - Beatriz Elena Adrada
- Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, CPB5.3208, Houston, TX 77030, USA
| | - Amy M Fowler
- Department of Radiology, Section of Breast Imaging and Intervention, University of Wisconsin - Madison, 600 Highland Avenue, Madison, WI 53792-3252, USA; Department of Medical Physics, University of Wisconsin Carbone Cancer Center, University of Wisconsin-Madison, 600 Highland Avenue, Madison, WI 53792-3252, USA
| | - Gaiane M Rauch
- Department of Abdominal Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, Unit 1473, Houston, TX 77030, USA; Department of Breast Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, Unit 1473, Houston, TX 77030, USA
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3
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Smith KA, Hunt KN, Rauch GM, Fowler AM. Molecular Breast Imaging in the Screening Setting. JOURNAL OF BREAST IMAGING 2023; 5:240-247. [PMID: 38416886 DOI: 10.1093/jbi/wbad011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Indexed: 03/01/2024]
Abstract
Early detection of breast cancer through screening mammography saves lives. However, the sensitivity of mammography for breast cancer detection is reduced in women with dense breast tissue. Imaging modalities for supplemental breast cancer screening include MRI, whole breast US, contrast-enhanced mammography, and molecular breast imaging (MBI). Molecular breast imaging with 99mTc-sestamibi is a functional imaging test to identify metabolically active areas in the breast with positioning analogous to mammography. Since 2011, there have been six large, published studies of screening MBI as a supplement to mammography involving over 6000 women from four different institutions. A multicenter, prospective clinical trial of 3000 women comparing breast cancer detection using screening digital breast tomosynthesis alone or in combination with MBI recently completed enrollment. This review focuses on the current evidence of MBI use for supplemental breast cancer screening, the strengths and limitations of MBI, and recent technological advances.
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Affiliation(s)
| | - Katie N Hunt
- Mayo Clinic, Department of Radiology, Rochester, MN, USA
| | - Gaiane M Rauch
- The University of Texas MD Anderson Cancer Center, Department of Breast Imaging, Houston, TX, USA
- The University of Texas MD Anderson Cancer Center, Department of Abdominal Imaging, Houston, TX, USA
| | - Amy M Fowler
- University of Wisconsin School of Medicine and Public Health, Department of Radiology, Madison, WI, USA
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
- University of Wisconsin School of Medicine and Public Health, Department of Medical Physics, Madison, WI, USA
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Maimone S, Morozov AP, Letter HP, Robinson KA, Wasserman MC, Li Z, Maxwell RW. Abbreviated Molecular Breast Imaging: Feasibility and Future Considerations. JOURNAL OF BREAST IMAGING 2022; 4:590-599. [PMID: 38416994 DOI: 10.1093/jbi/wbac060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Indexed: 03/01/2024]
Abstract
OBJECTIVE Molecular breast imaging (MBI) is a supplemental screening modality consistently demonstrating incremental cancer detection over mammography alone; however, its lengthy duration may limit widespread utilization. The study purpose was to assess feasibility of an abbreviated MBI protocol, providing readers with mediolateral oblique (MLO) projections only and assessing performance in lesion detection and localization. METHODS Retrospective IRB-exempt blinded reader study administered to 5 fellowship-trained breast imaging radiologists. Independent reads performed for 124 screening MBI cases, half abnormal and half negative/normal. Readers determined whether an abnormality was present, side of abnormality, and location of abnormality (medial/lateral). Abnormal cases had confirmatory biopsy or surgical pathology; normal cases had imaging follow-up ensuring true negative results. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess performance. A false negative result indicated that a reader failed to detect abnormal uptake; a false positive result indicated a reader incorrectly called an abnormality for a negative case. Tests for association included chi-square, Fisher-exact, and analysis of variance. RESULTS Mean reader performance for detecting abnormal uptake: sensitivity 96.8%, specificity 98.7%, PPV 98.8%, and NPV 96.9%. Accuracy in localizing lesions to the medial or lateral breast was 100%. There were no associations in reader performance with reader experience, reader technique, lesion morphology, or lesion pathology. Median lesion size was 1.0 cm (range: 0.4-8.0 cm). All readers correctly identified 97.7% (42/43) of lesions with malignant or elevated risk pathology. CONCLUSION An abbreviated MBI protocol (MLO images only) maintained high accuracy in lesion detection and localization.
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Affiliation(s)
- Santo Maimone
- Mayo Clinic Florida, Department of Radiology, Jacksonville, FL, USA
| | - Andrey P Morozov
- Mayo Clinic Florida, Department of Radiology, Jacksonville, FL, USA
| | - Haley P Letter
- Mayo Clinic Florida, Department of Radiology, Jacksonville, FL, USA
| | | | | | - Zhuo Li
- Mayo Clinic Florida, Department of Biostatistics, Jacksonville, FL, USA
| | - Robert W Maxwell
- Mayo Clinic Florida, Department of Radiology, Jacksonville, FL, USA
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5
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Downstream imaging following abnormal molecular breast imaging, lessons learned and suggestions for success. Clin Imaging 2022; 92:44-51. [DOI: 10.1016/j.clinimag.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 11/23/2022]
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Breast Cancer Screening Modalities, Recommendations, and Novel Imaging Techniques. Surg Clin North Am 2022; 103:63-82. [DOI: 10.1016/j.suc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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The Impact of Dense Breasts on the Stage of Breast Cancer at Diagnosis: A Review and Options for Supplemental Screening. Curr Oncol 2022; 29:3595-3636. [PMID: 35621681 PMCID: PMC9140155 DOI: 10.3390/curroncol29050291] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 04/23/2022] [Accepted: 04/25/2022] [Indexed: 11/16/2022] Open
Abstract
The purpose of breast cancer screening is to find cancers early to reduce mortality and to allow successful treatment with less aggressive therapy. Mammography is the gold standard for breast cancer screening. Its efficacy in reducing mortality from breast cancer was proven in randomized controlled trials (RCTs) conducted from the early 1960s to the mid 1990s. Panels that recommend breast cancer screening guidelines have traditionally relied on the old RCTs, which did not include considerations of breast density, race/ethnicity, current hormone therapy, and other risk factors. Women do not all benefit equally from mammography. Mortality reduction is significantly lower in women with dense breasts because normal dense tissue can mask cancers on mammograms. Moreover, women with dense breasts are known to be at increased risk. To provide equity, breast cancer screening guidelines should be created with the goal of maximizing mortality reduction and allowing less aggressive therapy, which may include decreasing the interval between screening mammograms and recommending consideration of supplemental screening for women with dense breasts. This review will address the issue of dense breasts and the impact on the stage of breast cancer at the time of diagnosis, and discuss options for supplemental screening.
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Covington MF, Parent EE, Dibble EH, Rauch GM, Fowler AM. Advances and Future Directions in Molecular Breast Imaging. J Nucl Med 2022; 63:17-21. [PMID: 34887334 PMCID: PMC8717200 DOI: 10.2967/jnumed.121.261988] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 11/16/2021] [Indexed: 12/11/2022] Open
Abstract
Molecular breast imaging (MBI) using 99mTc-sestamibi has advanced rapidly over the past decade. Technical advances allow lower-dose, higher-resolution imaging and biopsy capability. MBI can be used for supplemental breast cancer screening with mammography for women with dense breasts, as well as to assess neoadjuvant therapy response, evaluate disease extent, and predict breast cancer risk. This article highlights the current state of the art and future directions in MBI.
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Affiliation(s)
- Matthew F Covington
- Center for Quantitative Cancer Imaging, Huntsman Cancer Institute and University of Utah Department of Radiology and Imaging Sciences, Salt Lake City, Utah;
| | | | - Elizabeth H Dibble
- Warren Alpert Medical School of Brown University/Rhode Island Hospital Department of Diagnostic Imaging, Providence, Rhode Island
| | - Gaiane M Rauch
- M.D. Anderson Cancer Center, Departments of Abdominal and Breast Imaging, Houston, Texas; and
| | - Amy M Fowler
- University of Wisconsin School of Medicine and Public Health, Departments of Radiology and Medical Physics and the University of Wisconsin Carbone Cancer Center, Madison, Wisconsin
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Vegunta S, Kling JM, Patel BK. Supplemental Cancer Screening for Women With Dense Breasts: Guidance for Health Care Professionals. Mayo Clin Proc 2021; 96:2891-2904. [PMID: 34686363 DOI: 10.1016/j.mayocp.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/20/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022]
Abstract
Mammography is the standard for breast cancer screening. The sensitivity of mammography in identifying breast cancer, however, is reduced for women with dense breasts. Thirty-eight states have passed laws requiring that all women be notified of breast tissue density results in their mammogram report. The notification includes a statement that differs by state, encouraging women to discuss supplemental screening options with their health care professionals (HCPs). Several supplemental screening tests are available for women with dense breast tissue, but no established guidelines exist to direct HCPs in their recommendation of preferred supplemental screening test. Tailored screening, which takes into consideration the patient's mammographic breast density and lifetime breast cancer risk, can guide breast cancer screening strategies that are more comprehensive. This review describes the benefits and limitations of the various available supplemental screening tests to guide HCPs and patients in choosing the appropriate breast cancer screening.
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Affiliation(s)
- Suneela Vegunta
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, AZ.
| | - Juliana M Kling
- Division of Women's Health Internal Medicine, Mayo Clinic, Scottsdale, AZ
| | - Bhavika K Patel
- Division of Breast Imaging, Mayo Clinic Hospital, Phoenix, AZ
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Hunt KN. Molecular Breast Imaging: A Scientific Review. JOURNAL OF BREAST IMAGING 2021; 3:416-426. [PMID: 38424795 DOI: 10.1093/jbi/wbab039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Indexed: 03/02/2024]
Abstract
Molecular breast imaging (MBI) is a nuclear medicine technique that has evolved considerably over the past two decades. Technical advances have allowed reductions in administered doses to the point that they are now acceptable for screening. The most common radiotracer used in MBI, 99mTc-sestamibi, has a long history of safe use. Biopsy capability has become available in recent years, with early clinical experience demonstrating technically successful biopsies of MBI-detected lesions. MBI has been shown to be an effective supplemental screening tool in women with dense breasts and is also utilized for breast cancer staging, assessment of response to neoadjuvant chemotherapy, problem solving, and as an alternative to breast MRI in women who have a contraindication to MRI. The degree of background parenchymal uptake on MBI shows promise as a tool for breast cancer risk stratification. Radiologist interpretation is guided by a validated MBI lexicon that mirrors the BI-RADS lexicon. With short interpretation times, a fast learning curve for radiologists, and a substantially lower cost than breast MRI, MBI provides many benefits in the practices in which it is utilized. This review will discuss the current state of MBI technology, clinical applications of MBI, MBI interpretation, radiation dose associated with MBI, and the future of MBI.
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Affiliation(s)
- Katie N Hunt
- Mayo Clinic, Department of Radiology, Rochester, MN, USA
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11
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Molecular Breast Cancer Imaging in the Era of Precision Medicine. AJR Am J Roentgenol 2020; 215:1512-1519. [DOI: 10.2214/ajr.20.22883] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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12
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Jain R, Katz DR, Kapoor AD. The Clinical Utility of a Negative Result at Molecular Breast Imaging: Initial Proof of Concept. Radiol Imaging Cancer 2020; 2:e190096. [PMID: 33778735 PMCID: PMC7983715 DOI: 10.1148/rycan.2020190096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 04/28/2020] [Accepted: 05/27/2020] [Indexed: 11/11/2022]
Abstract
Purpose To calculate the negative predictive value (NPV) and false-negative rate (FNR) of molecular breast imaging (MBI) performed in patients who had low-suspicion index findings on mammograms and US images. Materials and Methods This retrospective study included patients who had undergone MBI between January 2015 and July 2017, who had index findings on screening mammograms and/or US images, and for whom either histopathologic results or a minimum of 1-year imaging follow-up results were available. A drawn dose of 8 mCi (296 MBq) of technetium 99m sestamibi was administered to all patients for MBI. The NPV and FNR of MBI was calculated for the cohort of 381 findings among 338 women (median age, 56 years; age range, 28-89 years) included in this study. Results Overall, 292 of the 381 (76.6%) MBI results were interpreted as negative. Of the 292, 27 patients underwent subsequent biopsies, results of which were negative for cancer; one patient underwent biopsy, and the result was positive for cancer; and 264 patients had true-negative findings based on follow-up imaging for a minimum of 1 year. Of the 89 MBI acquisitions interpreted as positive, there were 36 cancers. The NPV was calculated to be 99.7% (291 of 292, 95% confidence interval [CI]: 99.1%, 100%), and the FNR was 2.7% (one of 37, 95% CI: 0%, 7.9%). Interposing MBI reduced the number of biopsies by 67.5%. Conclusion The concept of the clinical utility of a negative MBI result may be valid but requires further testing.Keywords: Breast, Molecular Imaging-Cancer© RSNA, 2020.
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Affiliation(s)
- Ravi Jain
- From Middlesex Health, 28 Crescent St, Middletown, CT 06457
| | - Deanna R. Katz
- From Middlesex Health, 28 Crescent St, Middletown, CT 06457
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