new imaging modalities in breast cancer management dr rachel boutemy
TRANSCRIPT
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NEW IMAGING MODALITIES NEW IMAGING MODALITIES
IN BREAST CANCER IN BREAST CANCER
MANAGEMENTMANAGEMENT
Dr Rachel Boutemy
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MANAGEMENT OF BC PATIENTS
High quality staging
Neoadjuvant therapy: need to quantify early primary tumor response
MRI: high morphological accuracy, functional potentials
FDG PET: metabolic information
US and axillary nodal satus
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PRETHERAPEUTIC ASSESSMENT OF THE TUMOR EXTENT
Unquestionable indication
Factors for breast-conserving surgery ineligibility:
• Lobular histology
• Initial multicentric presentation (MRI>MAMMO)• Associated microcalcifications
[Newman 2002]
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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DOCUMENTING THE EXTENT OF RESIDUAL DISEASE
MRI more effective than clinical examination, mammography or US
Excellent correlation between histologic and MRI tumor size [Partridge AJR 2002, Rosen AJR 2003].
Two patterns of tumor shrinkage: concentric or
dendritic [Tozaki AJR 2005]
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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PREDICTION OF TUMOR RESPONSE/ MORPHOLOGY
Initial morphologic patterns Likelihood of response to treatmentRate of breast conservationPartial or complete response: 77% in pattern
1 >< 25% in pattern 5 [Esserman An surg oncol 2001]
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
Pattern 1 Pattern 2 Pattern 5Pattern 4Pattern 3
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PREDICTION OF TUMOR RESPONSE/ MORPHOLOGY
Volumetric measurementsReduction >65% tumor volume after 2 cycles of
chemotherapy predict major histopathological response [Martincich BCRT 2004].
Tumor volume more predictive than tumor diameter [Partridge AJR 2005].
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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PREDICTION OF TUMOR RESPONSE / FUNCTIONAL
Studies about tumor enhancement kinetics (neoangiogenesis) :reduction in the intensity of enhancement[Gilles Radiology 1994, Rieber Br JR 1997]
quantification of washout changes[El Khoury AJR 2005]
transfer constant measures[Padhani Radiology 2006]
…
to differentiate responders from non-responders
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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PREDICTION OF TUMOR RESPONSE / FUNCTIONAL
H MR Spectroscopy quantify total choline levelAdjunct to breast MRI:
improves specificity [Bartella Radiology 2006]. Monitoring therapy: changes in tCho
within 24 h after 1st dose of chemotherapy [Meisamy Radiology 2004]
Numerous technical limitations…
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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PREDICTION OF TUMOR RESPONSE / FUNCTIONAL
Diffusion-weighted MRI assess tumor cellularity
Differentiate benign from malignant[Woodhams J Comp Ass Tom 2005, Rubesova J. MRI. 2006].
False-positives (papilloma...) and false-negatives (DCIS…)
Preliminary results: early change in diffusion coefficient in response to chemotherapy[Pickles J. MRI 2005, Lee Clin. Can. Res. 2007].
Technical limitations…
MRI & THERAPY MONITORINGMRI & THERAPY MONITORING
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PET & BREAST CANCER STAGING
• Assessment of the metabolic activity of tissue
• Limited diagnostic value for detection
• Co registration FDG PET & CT : better diagnostic accuracy
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LOCOREGIONAL STAGING
• M+ in regional nodal sites outside axilla
• Mediastinal and internal mammary M+ : predict failure of primary therapy [Rosen Radiographics
2007]. • Specific role for patient
with inner-quadrant disease?
PET/CT & BREAST CANCER STAGINGPET/CT & BREAST CANCER STAGING
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SYSTEMIC STAGING
• Single whole body examination : Se 86%, Sp 90% distant M+ [Dose Nucl Med Com 2002]
• Limitations : lung microM+, brain, blastic bone M+
• Complementary to bone scintigraphy
PET & BREAST CANCER STAGINGPET & BREAST CANCER STAGING
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Bone Scinti Blastic M+ PET Lytic and intramedullary M+
BONE M+
PET & BREAST CANCER STAGINGPET & BREAST CANCER STAGING
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BONE M+ & SPECT/CT
PET & BREAST CANCER STAGING
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DETECTION OF BC RECURRENCE & RESTAGING
• 90% accuracy of PET >< 74% accuracy of conventional imaging [Gallowitsch Inv Rad 2003]
• FDG PET/CT comparing to whole body MRI :– Both very reliable for detection of organ M+
(94% MRI, 90% PET)– PET/CT more sens for lymph node involvement
[Schmidt EJR 2008]
PET & BREAST CANCER STAGINGPET & BREAST CANCER STAGING
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DETECTION OF BC RECURRENCE & RESTAGING
• Restaging cases of locally recurrent disease in up to 44%[Eubank AJR 2004]
• Rising levels of tumor marker in asymptomatic treated BC patients: change clinical management in 51%[Radan 2006]
PET & BREAST CANCER STAGINGPET & BREAST CANCER STAGING
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Tumor response to NAC
• FDG metabolism precedes morphologic changes
• Decrease FDG uptake is predictive of final response [Berriolo-Riedinger Eur J Nuc Med Mol Imag 2007, McDermott Br Ca Res Tr 2007, Rousseau J Clin Oncol 2006]
• Residual disease: lower accuracy of PET (43.5 %) than MRI (91 %)
PET & THERAPY MONITORINGPET & THERAPY MONITORING
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Recurrent or M+ disease• Response of M+ BC to
systemic therapy is prognostic [Franc Sem Roent 2007].
• Future : other PET agents (18F fluoroestradiol,18F-MISO marker for tumor hypoxia,18F fluoropaclitaxel…)
PET & THERAPY MONITORINGPET & THERAPY MONITORING
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Important prognostic indicator
• Axillary lymph node dissection overtreatment!
• Sentinel lymph node dissection (SLND)
• Noninvasive imaging test (PET, SCINTI, MRI …) to predict nodal M+ and obviate SLND??
AXILLARY NODAL STATUSAXILLARY NODAL STATUS
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AXILLARY US
• Suboptimal accuracy (10-50%FN, 5-35%FP)
• Sens. increases with tumor size[Koelliker Radiology2008].
• Morphology >> size ; relationship between adjacent LN
• M+ = subcapsular and cortical process
AXILLARY NODAL STATUSAXILLARY NODAL STATUS
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[STAVROS, BREAST ULTRASOUND 2004]
AXILLARY NODAL STATUSAXILLARY NODAL STATUS
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AXILLARY US + FNAC
• High specificity ≈ 100% [Alvarez AJR 2006].
• Target = thickened cortex (2 mm threshold) [Duchesne 2005].
• Cost saving by maximizing the rate of “one-step-surgery” [Genta W J Surgery 2007].
AXILLARY NODAL STATUSAXILLARY NODAL STATUS
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FUTURE ?
• Preliminary results of functional imaging techniques clinical role in routine?
• Need for prospective multi center trials, comparative
• ACRIN 6657: MRI in monitoring patients under neoadjuvant chemotherapy
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FUTURE ?
• MRI: reproducible and comparable protocols (help of the constructors!)
• Other imaging modalities : PET mammography,…
• Characterization of the lesions
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Thanks to Dr Delphine LUYX!
From the Nuclear Medecine CAVELL - CHIREC