Pilot study with [18F]DPA-714 PET-CT to explore tumor-associated-macrophages in triple negative breast cancer

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Background: Triple-negative breast cancer (TNBC) tends to exhibit aggressive behavior lacking from targeted therapies. Tumor-associated-macrophages (TAMs as M2 and M1 macrophages) are interest targets in TNBC to approach the tumor patient immunity. The mitochondrial translocator protein (TSPO), a sensitive marker for macrophages, could be interesting for TNBC micro-environment stratification. We performed a multicenter imaging pilot study (NCT04320030) using non-invasive [18F]DPA-714 (DPA), a TSPO PET radioligand, aiming at assessing immunity to define the immunotherapy possibilities in TNBC patients. Methods: All patients underwent TSPO genotyping (LAB: Low Affinity Binder, MAB: Mixed and HAB: High), [18F]FDG (FDG) and DPA PET-CT, macrophages immunochemistry and in vitro TSPO autoradiography using both tritiated PK11195 (PK) and DPA. Thorax PET-CT was acquired just after injection (DPA1) to 30 min, then from 45 min (DPA2) to 60 min, followed by a whole body PET-CT. Groups of interest (Macrophages immunochemistry and Genotype) were compared using Kruskal-Wallis test. Correlation between continuous parameters were determined using Spearman’s Rho. Results: A total of 13 TNBC patients were included. No adverse events occurred after DPA injection. For TSPO genotyping, 2/13 (15.5%) patients were LAB, 6/13 (46%) MAB and 5/13 (38.5%) HAB. All of them showed FDG and DPA uptake regardless of the patient's genotype without significant difference between the 3 groups. The DPA kinetics showed a tracer accumulation between DPA1 and DPA2, whatever patient genotypes, observed on SUVmax (p = 0.0015), SUVmean (p = 0.0015) and TL-DPA (p = 0.0024). A correlation between FDG and DPA1 either DPA2 tumor volume was shown, respectively (p = 0.0252 and 0.0067) as well as between the TLG (FDG) and the TL-DPA1 (p = 0.0346) regardless of the patient's genotype. Macrophages immunochemistry showed a tendency difference for M2 percentage (p = 0.09) between the 3 genotypes groups. In vitro binding ratio (PK/DPA), measured for both radioligands, on adjacent tumor slices, was 1.77 (1.35-2.21). A difference in this binding ratio was observed between MAB and HAB (Mean 1.68±0.36) compared to LAB 3.04±0.23 (p = 0.0367), suggesting that DPA binding is sensitive to TSPO genotype, unlike PK binding. Conclusions: Despite the limited population, all TNBC tumor patients were DPA positive with an accumulation over time. The total glycolysis and total DPA uptake in the tumor were correlated, which may link tumor aggressiveness and DPA uptake. These data were confirmed by a better sensitivity for HAB and MAB vs LAB. DPA seemed to be a promising tracer to explore non-invasively TNBC patient’s immunity. Clinical trial information: NCT04320030.

[Surgery or not on an atypical breast lesion? Taking anxiety into account in shared decision support from a prospective cohort of 300 patients]

INTRODUCTION

Organized and individual breast screening have been accompanied by an increase in the detection of "atypical breast lesions (ABL)". Recently, the NOMAT multicenter study proposed a predictive model of the risk of developing breast cancer after detection of an ABL in order to avoid surgical removal of "low-risk" lesions. It also aimed to provide information on psychological experience, in particularly anxiety, to assist in the shared medical decision process.

METHODS

Three hundred women undergoing surgery for ABL were included between 2015 and 2018 at 18 French centers. Women completed questionnaires before and after surgery assessing their level of anxiety (STAI-State, STAI-Trait), their level of tolerance to uncertainty, their perceived risk of developing a breast cancer, and their satisfaction with the management care.

RESULTS

One hundred nighty nine patients completed the STAI-Status before and after surgery. Overall, a decrease in anxiety level (35.4 vs 42.7, P<0.001) was observed. Anxious temperament and greater intolerance to uncertainty were significantly associated swith decreased anxiety (33%), whereas younger age was associated with increased anxiety (8%).

CONCLUSION

Surgery for ABL seems to be associated with only a few cases with an increase in anxiety and seems to increase the perception of the risk of developing breast cancer. Taking into account the psychological dimension remains in all cases essential in the process of shared therapeutic decision.

Three artificial intelligence data challenges based on CT and ultrasound

PURPOSE

The 2020 edition of these Data Challenges was organized by the French Society of Radiology (SFR), from September 28 to September 30, 2020. The goals were to propose innovative artificial intelligence solutions for the current relevant problems in radiology and to build a large database of multimodal medical images of ultrasound and computed tomography (CT) on these subjects from several French radiology centers.

MATERIALS AND METHODS

This year the attempt was to create data challenge objectives in line with the clinical routine of radiologists, with less preprocessing of data and annotation, leaving a large part of the preprocessing task to the participating teams. The objectives were proposed by the different organizations depending on their core areas of expertise. A dedicated platform was used to upload the medical image data, to automatically anonymize the uploaded data.

RESULTS

Three challenges were proposed including classification of benign or malignant breast nodules on ultrasound examinations, detection and contouring of pathological neck lymph nodes from cervical CT examinations and classification of calcium score on coronary calcifications from thoracic CT examinations. A total of 2076 medical examinations were included in the database for the three challenges, in three months, by 18 different centers, of which 12% were excluded. The 39 participants were divided into six multidisciplinary teams among which the coronary calcification score challenge was solved with a concordance index > 95%, and the other two with scores of 67% (breast nodule classification) and 63% (neck lymph node calcifications).

Diagnostic accuracy of breast MRI for patients with suspicious nipple discharge and negative mammography and ultrasound: a prospective study

OBJECTIVES

To evaluate the diagnostic accuracy of breast MRI in identifying lesions requiring excision for patients with suspicious nipple discharge but normal mammograms and ultrasounds.

METHODS

Between September 2013 and May 2019, 106 female participants (mean age 57.9 years) were consecutively included in this prospective multicenter study; 102 were retained for analysis. MRI was considered negative in the absence of suspicious enhancement and positive in cases of ipsilateral abnormal enhancement (BI-RADS 3 to 5). Final diagnoses were based on histological findings of surgical or percutaneous biopsies or at 1-year follow-up. We considered all lesions requiring excision found on pathology (papilloma, atypia, nipple adenomatosis, or cancer) as positive results. We considered spontaneous resolution of the discharge at 1 year as a negative result.

RESULTS

MRI showed ipsilateral abnormal enhancement in 54 patients (53%) revealing 46 lesions requiring excision (31 benign papillomas, 5 papillomas with atypia, 2 nipple adenomatosis, and 8 cancers) and 8 benign lesions not requiring excision. No suspicious enhancement was found in the remaining 48 participants (47%). Forty-two were followed up at 1 year with spontaneous resolution of the discharge and six underwent surgery (revealing 2 benign papillomas). MRI diagnostic accuracy for the detection of a lesion requiring excision was as follows: sensitivity 96%, specificity 85%, positive predictive value 85%, and negative predictive value 96%.

CONCLUSION

In patients with suspicious nipple discharge and normal mammogram and ultrasound, MRI demonstrates excellent performance to identify lesions for which excision is required. Normal MRI indicates it is safe to propose follow-up only management, thus avoiding unnecessary duct excision.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02819362 KEY POINTS: • Breast MRI can be useful for the management of patients with suspicious nipple discharge and negative mammogram and ultrasound. • MRI detected a lesion requiring excision in 46 participants (45%) with unexplained discharge. • If breast MRI is negative, follow-up is a safe alternative for these patients.

Prospective Multicenter Study Validate a Prediction Model for Surgery Uptake Among Women with Atypical Breast Lesions

BACKGROUND

Diagnosis of atypical breast lesions (ABLs) leads to unnecessary surgery in 75-90% of women. We have previously developed a model including age, complete radiological target excision after biopsy, and focus size that predicts the probability of cancer at surgery. The present study aimed to validate this model in a prospective multicenter setting.

- METHODS

Women with a recently diagnosed ABL on image-guided biopsy were recruited in 18 centers, before wire-guided localized excisional lumpectomy. Primary outcome was the negative predictive value (NPV) of the model.

RESULTS

The NOMAT model could be used in 287 of the 300 patients included (195 with ADH). At surgery, 12 invasive (all grade 1), and 43 in situ carcinomas were identified (all ABL: 55/287, 19%; ADH only: 49/195, 25%). The area under the receiving operating characteristics curve of the model was 0.64 (95% CI 0.58-0.69) for all ABL, and 0.63 for ADH only (95% CI 0.56-0.70). For the pre-specified threshold of 20% predicted probability of cancer, NPV was 82% (77-87%) for all ABL, and 77% (95% CI 71-83%) for patients with ADH. At a 10% threshold, NPV was 89% (84-94%) for all ABL, and 85% (95% CI 78--92%) for the ADH. At this threshold, 58% of the whole ABL population (and 54% of ADH patients) could have avoided surgery with only 2 missed invasive cancers.

CONCLUSION

The NOMAT model could be useful to avoid unnecessary surgery among women with ABL, including for patients with ADH.

CLINICAL TRIAL REGISTRATION

NCT02523612.

Report of a unique case of gemcitabine-induced radiation recall myelitis following spinal cord irradiation

Radiation recall is a rare phenomenon, defined as an acute inflammatory reaction in a previously irradiated area, after administration of anti-tumor agents, including chemotherapy. It is most commonly reported to trigger skin reactions but internal organ involvement is possible, particularly with gemcitabine. We report here a unique case of a gemcitabine-induced radiation recall myelitis following spinal irradiation. A 53-year-old patient received analgesic irradiation of the seventh thoracic vertebra (T7) in the context of metastatic non-small cell lung cancer, at conventional radiotherapy dose and fractionation. She was subsequently treated with gemcitabine and developed myelitis whose chronology is compatible with a radiation recall reaction. Spinal MRI confirmed a T6-T7 spinal cord enhancement, with an associated spinal cord oedema. Corticosteroids and supportive care did not improve myelitis symptoms. The patient died within a year of the radiation recall, due to a metastatic progression of lung cancer. This is, to our knowledge, the first reported case of gemcitabine-induced radiation recall myelitis and only the third case involving the spinal cord. Radiation recall is a rare and poorly understood phenomenon and all cases should be reported.

Preoperative Breast Magnetic Resonance Imaging in Women With Local Ductal Carcinoma in Situ to Optimize Surgical Outcomes: Results From the Randomized Phase III Trial IRCIS

PURPOSE

We evaluated the addition of breast magnetic resonance imaging (MRI) to standard radiologic evaluation on the re-intervention rate in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery.

PATIENTS AND METHODS

Women with biopsy-proven DCIS corresponding to a unifocal microcalcification cluster or a mass less than 30 mm were randomly assigned to undergo MRI or standard evaluation. The primary end point was the re-intervention rate for positive or close margins (< 2 mm) in the 6 months after randomization ( ClinicalTrials.gov identifier: NCT01112254).

RESULTS

A total of 360 patients from 10 hospitals in France were included in the study. Of the 352 analyzable patients, 178 were randomly assigned to the MRI arm, and 174 were assigned to the control arm. In the intent-to-treat analysis, 82 of 345 patients with the assessable end point were reoperated for positive or close margins within 6 months, resulting in a re-intervention rate of 20% (35 of 173) in the MRI arm and 27% (47 of 172) in the control arm. The absolute difference of 7% (95% CI, −2% to 16%) corresponded to a relative reduction of 26% (stratified odds ratio, 0.68; 95% CI, 0.41 to 1.1; P = .13). When considering only the per-protocol population with an assessable end point, the difference was 9% (stratified odds ratio, 0.59; 95% CI, 0.35 to 1.0; P = .05). Total mastectomy rates were 18% (31 of 176) in the MRI arm and 17% (30 of 173) in the control arm (stratified P = .93). For 100 lesions seen on MRI, nonmass-like enhancement was more predominant (82%) than mass enhancement (20%). Nevertheless, no specific morphologic and kinetic parameters for DCIS were identified.

CONCLUSION

The study did not show sufficient surgical improvement with the use of preoperative MRI to be clinically relevant in DCIS staging. However, this could be reconsidered with the improvement of new MRI sequences and new modalities in magnetic resonance techniques.

[Surgical management of non-palpable breast lesions in ambulatory care]

OBJECTIVE

The aim of our study was to assess if surgery for non-palpable breast lesions could be compatible with a walk-in case hospitalization setting.

METHOD

We retrospectively compared 75 patients with a traditional hospital stay to 68 patients with a walking case hospitalization. Overall 143 patients were treated during 1997. Studied parameters were: the quality of the surgical results, the duration of the hospital stay and the post operatives complications. Statistical analysis was realized using the chi 2 test.

RESULTS

There was no difference between the studied populations according to the quality of surgical results either the post operatives complications.

CONCLUSION

Surgery for non palpable breast lesions can be performed during a one day surgery. The reduction of the duration of the hospital stay decrease the cost of health care system. We should follow the evaluation of the walking case hospitalization for the breast cancer surgery especially when an axillary lymphadenectomy have to be performed.