2012 EDUCATIONAL BOOK - American Society of Clinical Oncology

in whom there were 46 additional lesions, only 14 of which
were malignant. 22
Positron Emission Mammography (PEM)
The sensitivity of whole-body 18-FDG PET for detection of
a primary breast cancer is low—approximately 40%. PEM
was developed to better evaluate the breasts. The scanner
again resembles a mammography machine. Twelve images
are generated for each view of the breast, providing a sort of
3D image. PEM is performed like whole-body PET: 4–6
hours of fasting, injection of about 10 mCi of FDG, followed
by a 1-hour rest period. Each view takes 10 minutes. PEM
can also be performed after a whole-body exam without
additional tracer. Multiple studies have shown sensitivities
of more than 90% (including DCIS) even for smaller lesions.
23 Specificity is also reported to be more than 90%. In
large trials comparing PEM to MRI in patients with known
breast cancer, MRI was more sensitive on a lesion level in
the ipsilateral breast, more sensitive in the contralateral
breast, but less specific. 24 PEM can be performed with
different tracers.
Radionuclide imaging is less expensive than MRI, and the
scanners themselves need less space. The limiting factor for
their use in routine screening is the high dose of radiation,
particularly to extramammary tissues: 50mGy to lower
large intestine for sestamibi and 59mGy to bladder was for
PEM. Vendors of both technologies are reporting promising
preliminary results using half the dose, but even those doses
may be too high to be used in yearly screening. Other
potential uses include preoperative staging, problem solv-
Author’s Disclosure of Potential Conflicts of Interest
Author
Maxine Jochelson*
*No relevant relationships to disclose.
Employment or
Leadership
Positions
Consultant or
Advisory Role
1. Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of
digital versus film mammography for breast-cancer screening. N Engl J Med.
2005;353:1773-1783.
2. Niklason LT, Christian BT, Niklason LE, et al. Digital tomosynthesis in
breast imaging. Radiology. 1997;205:399-406.
3. Kopans D, Moore R. Digital breast tomosynthesis (DBT) NCI 3000women
trial. RSNA. 2009.
4. Poplack SP, Tosteson TD, Kogel CA, Nagy HM. Digital breast tomosynthesis:
Initial experience in 98 women with abnormal digital screening
mammography. AJR Am J Roentgenol. 2007;189:616-623.
5. Noroozian M, Hadjiiski L, Rahnama-Moghadam S, et al. Digital breast
tomosynthesis is comparable to mammographic spot views for mass characterization.
Radiology. 2012;262:61-68.
6. Spangler ML, Zuley ML, Sumkin JH, et al. Detection and classification
of calcifications on digital breast tomosynthesis and 2D digital mammography:
A comparison. AJR Am J Roentgenol. 2011;196:320-324.
7. Destounis S, Murphy P, Seifert P, et al. Clinical experience with digital
breast tomosynthesis in the characterization and visualization of breast
microcalcifications. Amer J Radiol. 2011;196:A1-A3.
8. Gur D, Bandos AI, Rockette HE, et al. Localized detection and classification
of abnormalities on FFDM and tomosynthesis examinations rated
under an FROC paradigm. AJR Am J Roentgenol. 2011;196:737-741.
9. Morris EA, Liberman L, Ballon DJ, et al. MRI of occult breast carcinoma
in a high-risk population. AJR Am J Roentgenol. 2003;181:619-626.
10. Berg WA. Rationale for a trial of screening breast ultrasound: American
College of Radiology Imaging Network (ACRIN) 6666. AJR Am J
Roentgenol. 2003;180:1225-1228.
11. Dromain C, Thibault F, Adler G. Dual energy contrast-enhanced digital
68
ing, and assessment of treatment response in patients receiving
neoadjuvant chemotherapy.
MRI and Conclusions
Breast MRI is the gold standard breast imaging test
against which all other new technologies are compared,
particularly in terms of sensitivity, which is more than 95%.
The absence of radiation is a major asset. Initial inability to
diagnose DCIS and low specificity has been limiting. Both
have improved over the years, but the perception of poor
specificity remains. MRI is clearly the ideal way to screen
women at high risk for breast cancer, but is too expensive to
be used in larger populations, and good quality MRI is not
universally available. As newer technologies become available,
however, there are many lessons from the initial
experience with breast MRI that should be applied: 1) not all
MRI scanners/scans are equal, and although most of the
technologies discussed here are easier to perform, equipment
performance standards should be defined. 2) There is
always a learning curve in the interpretation of new technologies.
Minimal training requirements should be set. 3) A
vocabulary with standard terminology to describe abnormalities
and what they mean (such as the BIRADS system)
should be developed. 4) In this era of needed cost and
radiation containment, we cannot do every test on every
woman. It is imperative that in addition to determining
sensitivity, specificity, and other factors, we also learn in
which situations these new technologies can do the most
good.
Stock
Ownership Honoraria
REFERENCES
Research
Funding
Expert
Testimony
MAXINE JOCHELSON
Other
Remuneration
mammography: Preliminary Clinical Results 94th Scientific Assembly of the
RSNA 2007 Annual Meeting Program. 2007;326.
12. Diekmann F, Marx C, Jong R, et al. Diagnostic accuracy of contrastenhanced
digital mammography as an adjunct to mammography. ECR. 2007.
13. Dromain C, Thibault F, Muller S, et al. Dual-energy contrast-enhanced
digital mammography: Initial clinical results. Eur Radiol. 2011;21:565-574.
14. Jochelson M, Sung J, Dershaw DD, Heerdt A. Bilateral-Dual Energy
Contrast-enhanced Digital Mammography: Initial Experience. Presented at
96 th Annual RSNA Scientific Assembly and Annual Meeting; November 2010;
Chicago, IL.
15. Berg WA, Blume JD, Cormack JB, et al. Combined screening with
ultrasound and mammography vs mammography alone in women at elevated
risk of breast cancer. JAMA. 2008;299:2151-2163.
16. Kolb TM, Lichy J, Newhouse JH. Occult cancer in women with dense
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Radiology. 1998;207:191-199.
17. Kelly KM, Dean J, Comulada WS, Lee SJ. Breast cancer detection
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18. Shin HJ, Kim HH, Cha JH, et al. Automated ultrasound of the breast
for diagnosis: Interobserver agreement on lesion detection and characterization.
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19. Kohr J, Sung, J, Malak, S, et al. Impact of elastography on assessing
the likelihood of malignancy of ultrasound lesions. Poster presented at RSNA
97th Annual Meeting; 2011; Chicago, IL.
20. Hruska CB, Boughey JC, Phillips SW, et al. Scientific Impact Recognition
Award: Molecular breast imaging: A review of the Mayo Clinic experience.
Am J Surg. 2008;196:470-476.