JOURNAL CLUB: Molecular Breast Imaging at Reduced Radiation Dose for Supplemental Screening in Mammographically Dense Breasts

Rhodes, Deborah J.; Hruska, Carrie B.; Conners, Amy Lynn; Tortorelli, Cindy L.; Maxwell, Robert W.; Jones, Katie N.; Toledano, Alicia Y.; O’Connor, Michael K.

doi:10.2214/ajr.14.13357

Cited by 143 publications

(101 citation statements)

References 33 publications

(54 reference statements)

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“…Furthermore, there are an expanding number of states with legislation on breast density driven by patient advocacy group concern regarding the limited sensitivity of mammography in women with dense breasts. The work reported by Brem et al in this issue, as well as other recently published studies, are important to ensure that clinical use of supplemental screening approaches continue to be evidence-based (4,20). Determination of the best supplemental screening tool will likely require direct comparison of the cancer detection rate, recall rate, and number of false-positive examinations in large, prospective multiinstitutional trials and include additional considerations such as radiation dose, cost, and accessibility.…”

Section: See Page 678mentioning

confidence: 98%

“…The reduction in administered activity did not adversely affect image quality and did not have a statistically significant effect on the cancer detection rate. The resulting whole-body effective dose equivalent of the standard-dose examinations ranges from 5.9 to 9.4 mSv, which decreases to approximately 2.4 mSv for the low-dose examinations (19,20). For comparison, the effective dose equivalent of digital mammography is approximately 0.44 mSv and 1.2 mSv for digital mammography combined with tomosynthesis (19).…”

Section: See Page 678mentioning

confidence: 99%

“…For comparison, the effective dose equivalent of digital mammography is approximately 0.44 mSv and 1.2 mSv for digital mammography combined with tomosynthesis (19). Technologic improvements in instrumentation design combined with optimized patient preparation to increase radiopharmaceutical uptake have been pursued to reduce the radiation exposure to levels feasible to consider for breast cancer screening programs (20)(21)(22)(23). Continued research into dose reduction methods or consideration of less frequent screening intervals will facilitate broader acceptance of radionuclidebased supplemental screening approaches in clinical practice.…”

Section: See Page 678mentioning

confidence: 99%

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Molecular Imaging Approaches for Supplemental Screening in Women at Increased Breast Cancer Risk

Fowler¹

2016

J Nucl Med

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Mammography is an effective screening method that reduces breast cancer mortality (1). However, mammography is not a perfect test and its sensitivity is diminished in women with dense breast tissue (2). For women at increased breast cancer risk, the use of imaging modalities in addition to mammography, termed supplemental screening, can improve the overall cancer detection rate. Current guidelines recommend MRI for supplemental screening in women with greater than 20% lifetime risk of breast cancer (3). For women who cannot tolerate MRI, have mammographically dense breast tissue, or have an intermediate lifetime risk of breast cancer, screening ultrasound can be considered (3). However, these techniques have some drawbacks, which have fueled interest in alternative functional imaging-based methods for supplemental screening in high-risk women. In this issue of The Journal of Nuclear Medicine, Brem et al. investigate the diagnostic performance of a molecular imaging approach for supplemental breast cancer screening (4). See page 678Breast-specific g-imaging (BSGI) is a Food and Drug Administrationapproved radionuclide-based technique that can be used to detect breast cancer (5,6). A high-spatial-resolution, small-field-of-view g-camera detects and localizes g-ray energy emitted by the radiopharmaceutical 99m Tc-methoxyisobutylisonitrile (sestamibi), which preferentially accumulates in malignant breast cells with increased vascular supply and concentration of mitochondria compared with surrounding normal breast tissue. Images are acquired immediately after intravenous injection of the radiopharmaceutical, with the patient seated in standard mammographic views (craniocaudal and mediolateral oblique views) with the breast in mild compression for a total of approximately 40 min. Interpretation of breast-specific g-images follows a standardized lexicon and results in assessment categories and recommendations that parallel those of other imaging modalities outlined by the American College of Radiology Breast Imaging-Reporting and Data System (BI-RADS) (7-9).Although several studies have evaluated the performance of BSGI for diagnosing breast cancer in a heterogeneous mix of clinical indications (10), data regarding the application of BSGI for supplemental screening for women at increased breast cancer risk are sparse. The study by Brem et al. is a single-institution, retrospective review of asymptomatic, increased-risk women undergoing BSGI from 2010 to 2014 whose most recent screening mammogram showed no suspicious abnormalities (4). The study population consisted of 849 women ranging in age from 26 to 83 y with a personal history of treated breast cancer, a family history of breast cancer, a personal history of an atypical or high-risk breast biopsy result, or a known genetic predisposition to breast cancer development. BSGI detected 14 mammographically occult cancers in 849 women, resulting in a supplemental cancer detection rate of 16.5 per 1,000 women screened. Furthermore, mammographic breast density did not affe...

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Section: See Page 678mentioning

confidence: 98%

Section: See Page 678mentioning

confidence: 99%

Section: See Page 678mentioning

confidence: 99%

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Molecular Imaging Approaches for Supplemental Screening in Women at Increased Breast Cancer Risk

Fowler¹

2016

J Nucl Med

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“…More extensively, a Mayo Clinic group has explored using 99m Tc-sestamibi and dual-head cameras for supplemental screening in women with dense breasts (45,46). As shown in Table 1, the sensitivity and specificity of MBI compare quite favorably with other methods of supplemental screening.…”

Section: Screeningmentioning

confidence: 99%

Nuclear Breast Imaging: Clinical Results and Future Directions

Berg

2016

J Nucl Med

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Interest in nuclear breast imaging is increasing because of technical improvements in dedicated devices that allow the use of relatively low doses of radiotracers with high sensitivity for even small breast cancers. For women with newly diagnosed cancer, primary chemotherapy is often recommended, and improved methods of assessing treatment response are of interest. With widespread breast density notification, functional rather than anatomic methods of screening are of increasing interest as well. For a cancer imaging technology to be adopted, several criteria must be met that will be discussed: evidence of clinical benefit with minimal harm, standardized interpretive criteria, direct biopsy guidance, and acceptable cost-effectiveness. Twor adiotracers have been used widely to depict breast cancer: the g-emitting 99m Tc-sestamibi ( 99m Tc-methoxyisobutylisonitrile), 140 keV, half-life of 6 h, originally developed as a myocardial perfusion agent; and the positron-emitting glucose analog 18 F-FDG, 511 keV, half-life of 2 h. Standard lead shielding as is used in a mammography suite is sufficient when using 99m Tc-sestamibi. Using 18 F-FDG requires much more extensive shielding and may not be feasible because of workspaces above or below the planned unit. State licensing requirements for nuclear medicine must be considered; typically, a hot lab with oversight by a trained nuclear medicine technologist and a physicist is required (1).Both 99m Tc-sestamibi and 18 F-FDG were initially studied for breast cancer using whole-body scanners. Low sensitivity to invasive cancers smaller than 1 cm was observed with whole-body g-camera imaging in a prospective multicenter series at 48.2%, compared with 74.2% for larger tumors (2); detection of small cancers, particularly small invasive cancers, is a major goal of breast imaging. Similar results were observed with whole-body PET, with sensitivity to invasive tumors 2 cm or smaller of only 30 of 44 (68%) compared with 57 of 62 (92%) for larger cancers (3).Dedicated breast g-camera imaging can be performed with singledetector scintillating-crystal systems such as breast-specific g-imaging (BSGI) (Dilon Technologies) with a 20 · 15 cm field of view, 3.3-mm pixel size; or using dual-head cadmium-zinc-telluride detector systems, often referred to as molecular breast imaging (MBI) (GE Healthcare, with a 24 · 16 cm field of view and 2.5-mm pixel size; or Gamma Medica, Inc., with a 20 · 16 cm field of view and 1.6 mm pixel size). Both approaches use positioning similar to that of mammography, with the breast gently stabilized between a compression paddle and the detector (BSGI) or between 2 detectors (MBI). It is important to include mammographic technologists in the positioning of the patients, at least for a minimum number of cases (e.g., 25), to ensure full inclusion of posterior tissues for both a craniocaudal and a mediolateral oblique (MLO) acquisition. Particularly with the dualhead systems, it can be difficult to prevent skin folds or to ensure that the nipple is in profile becau...

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“…Studies have shown an improvement in breast cancer detection in dense breast, with cancer detection rate per 1000 women increasing from 3.2 for mammography alone to 12.0% with supplemental MBI. 153 A review of the literature shows sensitivity ranging from 91% -96%, with specificity of 60% -77% for MBI alone, 154 and meta-analysis of published literature reported 95% sensitivity and 80% specificity. 155 A major limitation of MBI is its high radiation dose which has the potential to cause mutation to the rapidly dividing cells in dense breasts.…”

Section: Imaging the Dense Breastmentioning

confidence: 99%

Breast composition: Measurement and clinical use

Ekpo¹,

Hogg²,

Highnam³

et al. 2015

Radiography

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Breast density is a measure of the extent of radiodense fibroglandular tissue in the breast. The risk of developing breast cancer and the risk of missing cancer at screening rise with higher breast density. In this paper, the historical background to breast density measurement is outlined and current evidence based practice is explained. The relevance of breast density knowledge to mammographic practice and image interpretation is considered in the light of clinical assessment and notification of mammographic breast density (MBD). The current work also discusses risk stratification for decisionmaking regarding screening frequency and better modalities for earlier detection of breast cancer in the dense breast. Automated volumetric approaches are explained while ultrasound, digital breast tomosynthesis, molecular breast imaging, and magnetic resonance imaging are introduced as valuable adjuncts to digital mammography for imaging the dense breast. The work concludes on the important note that screened women should be notified of their breast density, and such notification should be accompanied with clear and adequate information about breast density and cancer risk, strategies associated with lower MBD, as well as best screening intervals and pathways for women with dense breasts. Adoption of these strategies may be crucial to early detection and treatment of cancer and improving survival from the disease.

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JOURNAL CLUB: Molecular Breast Imaging at Reduced Radiation Dose for Supplemental Screening in Mammographically Dense Breasts

Cited by 143 publications

References 33 publications

Molecular Imaging Approaches for Supplemental Screening in Women at Increased Breast Cancer Risk

Molecular Imaging Approaches for Supplemental Screening in Women at Increased Breast Cancer Risk

Nuclear Breast Imaging: Clinical Results and Future Directions

Breast composition: Measurement and clinical use

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