George Peters Award: How does breast-specific gamma imaging affect the management of patients with newly diagnosed breast cancer?

doi:10.1016/j.amjsurg.2009.06.016

The American Journal of Surgery

Volume 198, Issue 4, October 2009, Pages 470-474

https://doi.org/10.1016/j.amjsurg.2009.06.016 Get rights and content

Abstract

Background

We sought to determine the number of patients with known breast cancer who were found to have an additional, mammographically occult lesion detected on breast-specific gamma imaging (BSGI).

Methods

An institutional review board–approved review of all patients who underwent BSGI at Beth Israel Medical Center from 2006 to 2008 was performed.

Results

A total of 82 patients underwent BSGI for newly diagnosed breast cancer. Of these, 18 had an additional abnormality, and 17 were biopsied. There were 4 cases of invasive ductal carcinoma, 1 invasive lobular carcinoma, 1 ductal carcinoma in situ, 1 lobular carcinoma in situ, 2 papillomas, and 8 benign biopsies. One patient proceeded directly to mastectomy and an area of ductal carcinoma in situ was found, corresponding to the BSGI.

Conclusions

In our study group, 22% of patients had a surgical change in management based on BSGI findings. BSGI detected additional carcinoma in 9%. BSGI plays an important role in the clinical management of patients with known breast cancer.

Section snippets

Materials and Methods

An Institutional Review Board–approved, retrospective chart review was performed on 942 consecutive BSGI scans performed on a total of 790 patients between October 1, 2005, and December 31, 2008. Patients were categorized according to indication for the scan (eg, for screening or for a new diagnosis of breast cancer). BSGI scans were obtained on women as an adjuvant screening tool for those at high risk or as a complement to targeted mammography and/or ultrasound as part of the evaluation of a

Results

Of the 942 BSGI scans performed, there were 82 that were completed on patients with a biopsy-proven, new diagnosis of cancer. These 82 patients comprised our study population. The mean age was 53 years (range, 33–83 y) and the mean tumor size was 1.5 cm (range, .1–5 cm). In cases in which patients had more than 1 known malignancy, we used the largest tumor to calculate the mean tumor size. When calculating the mean tumor size, ductal carcinoma in situ (DCIS) was not included. There were 55

Comments

Mammography has been shown to decrease breast cancer mortality by 20% to 35% in women aged 50 to 69 years.¹¹ However, even with the advent of digital technique, there are still limitations in the sensitivity and specificity of mammography, especially for those women with dense breasts. Generally, the sensitivity of mammography in the community setting is approximately 75%, meaning that 25% of patients diagnosed with breast cancer had a false-negative mammogram in the 1 to 2 years before their

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Cancers missed were usually small or outside the field of view. In a retrospective study41 of 82 patients who underwent BSGI for newly diagnosed breast cancer, 18 (22%) were found to have additional suspicious findings based on BSGI including 7 of 82 (8.5%) with additional malignancy (Fig. 5). Kim42 evaluated the adjunctive benefits of BSGI compared with MR imaging in 97 lesions in 66 patients with breast cancer with dense breasts and showed comparable sensitivity for BSGI and MR imaging at 88.8% (23 of 26; 95% CI, 69.8% to 97.6%) and 92.3% (24 of 26; 95% CI, 74.9% to 99.1%) respectively.
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BSGI performed following mammography was reported to detect additional clinically occult ipsilateral or contralateral tumor foci or the in situ component sited around invasive tumors changing surgical management in 18.2% of the cases and ruling out malignancy in patients with BI-RADS four findings.36 In a study on 159 women who had a single suspicious breast lesion on physical examination and mammography, BSGI identified additional occult tumor sites in 9%; in 6% in the same breast as the index lesion; and in 3% in the contralateral breast.49 In a recent publication on 286 patients diagnosed with 390 invasive tumor foci.
The scope of the current article is the clinical role of gamma cameras dedicated for breast imaging and ^99mTc-MIBI tumor-seeking tracer, as both a screening modality among a healthy population and as a diagnostic modality in patients with breast cancer. Such cameras are now commercially available. The technology utilizing a camera composed of a NaI (Tl) detector is termed breast-specific gamma imaging. The technology of dual-headed camera composed of semiconductor cadmium zinc telluride detectors that directly converts gamma-ray energy into electronic signals is termed molecular breast imaging. Molecular breast imaging system has been installed at the Department of Nuclear medicine at the Tel Aviv Sourasky Medical Center, Tel Aviv in 2009. The article reviews the literature well as our own experience.
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In our series, the sensitivity, specificity, and accuracy were all higher for BSGI than that of MRI. Killelea et al4 also reported a similar series in which BSGI compared favorably with MRI in newly diagnosed breast cancer. Keto et al5 reported a series specifically comparing BSGI with MRI for evaluation of ductal carcinoma in situ and found that the sensitivity between the 2 modalities was comparable.
Both MRI and breast-specific gamma imaging are tools for surgical planning in newly diagnosed breast cancer. Breast-specific gamma imaging (BSGI) is used less frequently although it is of similar utility and lower cost. We compared the diagnostic and cost efficacy of BSGI with MRI.
Retrospective review of 1,480 BSGIs was performed in a community breast health center, 539 had a new diagnosis of cancer, 75 patients having both MRI and BSGI performed within 2 months of each other. Institutional charges for BSGI ($850) and MRI ($3,381) were noted.
BSGI had a sensitivity of 92%, specificity of 73%, positive predictive value of 78%, and negative predictive value of 90%. This compared favorably with MRI that had sensitivity of 89%, specificity 54%, positive predictive value 67%, and negative predictive value 83%. The accuracy of BSGI was higher at 82% vs MRI at 72%. Total cost of MRI imaging was $253,575 vs BSGI at $63,750.
BSGI is a cost-effective and accurate imaging study for further evaluation of dense breast tissue and new diagnosis of cancer.
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In our series, the sensitivity, specificity, and accuracy were all higher for BSGI than that of MRI. Killelea et al4 also reported a similar series in which BSGI compared favorably with MRI in newly diagnosed breast cancer. Keto et al5 reported a series specifically comparing BSGI with MRI for evaluation of ductal carcinoma in situ and found that the sensitivity between the 2 modalities was comparable.
Both MRI and breast-specific gamma imaging are tools for surgical planning in newly diagnosed breast cancer. Breast-specific gamma imaging (BSGI) is used less frequently although it is of similar utility and lower cost. We compared the diagnostic and cost efficacy of BSGI with MRI.
Retrospective review of 1,480 BSGIs was performed in a community breast health center, 539 had a new diagnosis of cancer, 75 patients having both MRI and BSGI performed within 2 months of each other. Institutional charges for BSGI ($850) and MRI ($3,381) were noted.
BSGI had a sensitivity of 92%, specificity of 73%, positive predictive value of 78%, and negative predictive value of 90%. This compared favorably with MRI that had sensitivity of 89%, specificity 54%, positive predictive value 67%, and negative predictive value 83%. The accuracy of BSGI was higher at 82% vs MRI at 72%. Total cost of MRI imaging was $253,575 vs BSGI at $63,750.
BSGI is a cost-effective and accurate imaging study for further evaluation of dense breast tissue and new diagnosis of cancer.
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In patients at high risk for breast cancer, BSGI had an overall sensitivity of 96.4% and specificity of 59.5%.30 In patients with known breast cancer, BSGI detected additional breast cancers in 9% of patients and 22% of patients had a surgical management change because of BSGI findings.31 In another retrospective analysis of patients undergoing BSGI, 11% of patients with Breast Imaging-Reporting and Data System (BI-RADS)32 1, 2, or 3 had positive BSGI, and 17% of these were positive for malignancy (Table 3 for BI-RADS definitions).
Conventional mammography is a screening procedure constrained by low specificity in the detection of breast cancer. Approximately 40% of women undergoing mammography screening have dense breast tissue, and conventional mammographic imaging has a sensitivity range of only 50%-85% for malignant lesions. Magnetic resonance imaging (MRI) is now recommended for breast cancer screening in high-risk patients. However, approximately 15% of patients cannot tolerate MRI. These are the clinical situations in which positron emission mammography (PEM) and breast-specific gamma (BSG) camera systems fulfill a need for primary breast cancer imaging. Because breast cancer is the most common malignancy and the second most common cause of cancer death among women, many nuclear medicine imaging techniques are essential in the evaluation and therapy of patients with this disease. Nuclear medicine surgical techniques consist of sentinel lymph node localization and the use of radiolabeled seeds for intraoperative localization of nonpalpable breast cancers. The Food and Drug Administration (FDA) has approved the PEM Flex Solo II scanner, which has the capability for stereotactic biopsy, with an array of pixelated lutetium yttrium orthosilicate (LYSO) crystals, position-sensitive photomultiplier tubes (PS-PMT), and a spatial resolution of 2.4 mm. Clear PEM is a scanner in development with cerium-doped LYSO (LYSO:Ce) crystals, multipixel avalanche photodiodes, depth of interaction measurement with a resolution of 1.3 mm. The Dilon 6800 Gamma Camera is a BSG device approved by the FDA with stereotactic biopsy guidance capability, a pixelated array of sodium iodide crystals, PS-PMTs, and an extrinsic spatial resolution of 6 mm at 3 cm from the camera. GE has just received clearance from the FDA for a molecular breast imaging camera, the Discovery NM 750b, with pixelated cadmium zinc telluride crystals, semiconductor photoelements and an extrinsic resolution of 3.5 mm at 3 cm. The Society of Nuclear Medicine has issued guidelines for BSG camera image interpretation recommendations and clinical indications. Different crystals and camera architectures are under investigation to further improve resolution for both PEM and BSG imaging.

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The American Society of Breast SurgeonsGeorge Peters Award: How does breast-specific gamma imaging affect the management of patients with newly diagnosed breast cancer?

Abstract

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Comments

Magn Reson Imaging Clin N Am

Mayo Clin Proc

Am J Surg

Am J Surg

Effects of age, breast density, ethnicity, and estrogen replacement therapy on screening mammographic sensitivity and cancer stage diagnosis: review of 183,134 screening mammograms in Albuquerque, New Mexico

Radiology

Diagnostic performance of digital versus film mammography for breast-cancer screening

N Engl J Med

Mammographic features of “early” breast cancer

AJR Am J Roentgenol

False-negative mammograms in patients with breast cancer

Can J Surg

Prone scintimammography in patients with suspicion of carcinoma of the breast

J Am Coll Surg

Occult breast cancer: scintimammography with high-resolution breast-specific gamma camera in women at high risk for breast cancer

Radiology

High-resolution scintimammography: a pilot study

J Nucl Med

Scintimammography with dedicated breast camera detects and localizes occult carcinoma

J Nucl Med

The American Society of Breast Surgeons
George Peters Award: How does breast-specific gamma imaging affect the management of patients with newly diagnosed breast cancer?