Top

European Journal of Nuclear Medicine and Molecular Imaging

Published in:

Open Access 01-02-2018 | Original Article

Added value of dedicated axillary hybrid 18F-FDG PET/MRI for improved axillary nodal staging in clinically node-positive breast cancer patients: a feasibility study

Authors: Thiemo J. A. van Nijnatten, B. Goorts, S. Vöö, M. de Boer, L. F. S. Kooreman, E. M. Heuts, J. E. Wildberger, F. M. Mottaghy, M. B. I. Lobbes, M. L. Smidt

Published in: European Journal of Nuclear Medicine and Molecular Imaging | Issue 2/2018

Abstract

Purpose

To investigate the feasibility and potential added value of dedicated axillary 18F-FDG hybrid PET/MRI, compared to standard imaging modalities (i.e. ultrasound [US], MRI and PET/CT), for axillary nodal staging in clinically node-positive breast cancer.

Methods

Twelve patients with clinically node-positive breast cancer underwent axillary US and dedicated axillary hybrid 18F-FDG PET/MRI. Nine of the 12 patients also underwent whole-body PET/CT. Maximum standardized uptake values (SUVmax) were measured for the primary breast tumor and the most FDG-avid axillary lymph node. A positive axillary lymph node on dedicated axillary hybrid PET/MRI was defined as a moderate to very intense FDG-avid lymph node. The diagnostic performance of dedicated axillary hybrid PET/MRI was calculated by comparing quantitative and its qualitative measurements to results of axillary US, MRI and PET/CT. The number of suspicious axillary lymph nodes was subdivided as follows: N0 (0 nodes), N1 (1–3 nodes), N2 (4–9 nodes) and N3 (≥ 10 nodes).

Results

According to dedicated axillary hybrid PET/MRI findings, seven patients were diagnosed with N1, four with N2 and one with N3. With regard to mean SUVmax, there was no significant difference in the primary tumor (9.0 [±5.0] vs. 8.6 [±5.7], p = 0.678) or the most FDG-avid axillary lymph node (7.8 [±5.3] vs. 7.7 [±4.3], p = 0.767) between dedicated axillary PET/MRI and PET/CT. Compared to standard imaging modalities, dedicated axillary hybrid PET/MRI resulted in changes in nodal status as follows: 40% compared to US, 75% compared to T2-weighted MRI, 40% compared to contrast-enhanced MRI, and 22% compared to PET/CT.

Conclusions

Adding dedicated axillary 18F-FDG hybrid PET/MRI to diagnostic work-up may improve the diagnostic performance of axillary nodal staging in clinically node-positive breast cancer patients.

Available only for authorised users

Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65:87–108. https://doi.org/10.3322/caac.21262.CrossRefPubMed

Howlader N, Noone AM, Krapcho M, Miller D, Bishop K, Altekruse SF, Kosary CL, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA (eds). SEER Cancer Statistics Review, 1975–2013, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2013/, based on November 2015 SEER data submission, posted to the SEER website, April 2016.

Senkus E, Kyriakides S, Ohno S, Penault-Llorca F, Poortmans P, Rutgers E, et al. Primary breast cancer: ESMO clinical practice guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2015;26(Suppl 5):v8–30. https://doi.org/10.1093/annonc/mdv298.CrossRefPubMed

Kaufmann M, von Minckwitz G, Mamounas EP, Cameron D, Carey LA, Cristofanilli M, et al. Recommendations from an international consensus conference on the current status and future of neoadjuvant systemic therapy in primary breast cancer. Ann Surg Oncol. 2012;19:1508–16. https://doi.org/10.1245/s10434-011-2108-2.CrossRefPubMed

Schipper RJ, van Roozendaal LM, de Vries B, Pijnappel RM, Beets-Tan RG, Lobbes MB, et al. Axillary ultrasound for preoperative nodal staging in breast cancer patients: is it of added value? Breast. 2013;22:1108–13. https://doi.org/10.1016/j.breast.2013.09.002.CrossRefPubMed

van Nijnatten TJ, Ploumen EH, Schipper RJ, Goorts B, Andriessen EH, Vanwetswinkel S, et al. Routine use of standard breast MRI compared to axillary ultrasound for differentiating between no, limited and advanced axillary nodal disease in newly diagnosed breast cancer patients. Eur J Radiol. 2016;85:2288–94. https://doi.org/10.1016/j.ejrad.2016.10.030.CrossRefPubMed

Kuijs VJ, Moossdorff M, Schipper RJ, Beets-Tan RG, Heuts EM, Keymeulen KB, et al. The role of MRI in axillary lymph node imaging in breast cancer patients: a systematic review. Insights Imaging. 2015;6:203–15. https://doi.org/10.1007/s13244-015-0404-2.CrossRefPubMedPubMedCentral

Koolen BB, Valdes Olmos RA, Elkhuizen PH, Vogel WV, Vrancken Peeters MJ, Rodenhuis S, et al. Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy. Breast Cancer Res Treat. 2012;135:231–40. https://doi.org/10.1007/s10549-012-2179-1.CrossRefPubMed

Huellner MW, Appenzeller P, Kuhn FP, Husmann L, Pietsch CM, Burger IA, et al. Whole-body nonenhanced PET/MR versus PET/CT in the staging and restaging of cancers: preliminary observations. Radiology. 2014;273:859–69. https://doi.org/10.1148/radiol.14140090.CrossRefPubMed

10.

NABON. National breast cancer guideline, Oncoline. 2012. www.oncoline.nl/breastcancer. Accessed 17 May 2017.

11.

Neal CH, Daly CP, Nees AV, Helvie MA. Can preoperative axillary US help exclude N2 and N3 metastatic breast cancer? Radiology. 2010;257:335–41. https://doi.org/10.1148/radiol.10100296.CrossRefPubMed

12.

Boellaard R, Delgado-Bolton R, Oyen WJ, Giammarile F, Tatsch K, Eschner W, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging. 2015;42:328–54. https://doi.org/10.1007/s00259-014-2961-x.CrossRefPubMed

13.

Baltzer PA, Dietzel M, Burmeister HP, Zoubi R, Gajda M, Camara O, et al. Application of MR mammography beyond local staging: is there a potential to accurately assess axillary lymph nodes? Evaluation of an extended protocol in an initial prospective study. AJR Am J Roentgenol. 2011;196:W641–7. https://doi.org/10.2214/AJR.10.4889.CrossRefPubMed

14.

Farshchian N, Tamari S, Farshchian N, Madani H, Rezaie M, Mohammadi-Motlagh HR. Diagnostic value of chemical shift artifact in distinguishing benign lymphadenopathy. Eur J Radiol. 2011;80:594–7. https://doi.org/10.1016/j.ejrad.2010.10.005.CrossRefPubMed

15.

Lambregts DM, Heijnen LA, Maas M, Rutten IJ, Martens MH, Backes WH, et al. Gadofosveset-enhanced MRI for the assessment of rectal cancer lymph nodes: predictive criteria. Abdom Imaging. 2013;38:720–7. https://doi.org/10.1007/s00261-012-9957-4.CrossRefPubMed

16.

Aukema TS, Straver ME, Peeters MJ, Russell NS, Gilhuijs KG, Vogel WV, et al. Detection of extra-axillary lymph node involvement with FDG PET/CT in patients with stage II-III breast cancer. Eur J Cancer. 2010;46:3205–10. https://doi.org/10.1016/j.ejca.2010.07.034.CrossRefPubMed

17.

Gradishar WJ, Anderson BO, Balassanian R, Blair SL, Burstein HJ, Cyr A, et al. Invasive breast cancer version 1.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2016;14:324–54.CrossRef

18.

Giuliano AE, Ballman K, McCall L, Beitsch P, Whitworth PW, Blumencranz P, et al. Locoregional recurrence after sentinel lymph node dissection with or without Axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial. Ann Surg. 2016;264:413–20. https://doi.org/10.1097/SLA.0000000000001863.CrossRefPubMedPubMedCentral

19.

Teixeira SC, Koolen BB, Elkhuizen PH, Vrancken Peeters MT, Stokkel MP, Rodenhuis S, et al. PET/CT with 18F-FDG predicts short-term outcome in stage II/III breast cancer patients upstaged to N2/3 nodal disease. Eur J Surg Oncol. 2017;43:625–35. https://doi.org/10.1016/j.ejso.2016.10.012.CrossRefPubMed

20.

Grueneisen J, Nagarajah J, Buchbender C, Hoffmann O, Schaarschmidt BM, Poeppel T, et al. Positron emission tomography/magnetic resonance imaging for local tumor staging in patients with primary breast cancer: a comparison with positron emission tomography/computed tomography and magnetic resonance imaging. Investig Radiol. 2015;50:505–13. https://doi.org/10.1097/RLI.0000000000000197.CrossRef

21.

Melsaether AN, Raad RA, Pujara AC, Ponzo FD, Pysarenko KM, Jhaveri K, et al. Comparison of whole-body (18)F FDG PET/MR imaging and whole-body (18)F FDG PET/CT in terms of lesion detection and radiation dose in patients with breast cancer. Radiology. 2016;281:193–202. https://doi.org/10.1148/radiol.2016151155.CrossRefPubMedPubMedCentral

22.

Teixeira SC, Koolen BB, Vogel WV, Wesseling J, Stokkel MP, Vrancken Peeters MJ, et al. Additional prone 18F-FDG PET/CT acquisition to improve the visualization of the primary tumor and regional lymph node metastases in stage II/III breast cancer. Clin Nucl Med. 2016;41:e181–6. https://doi.org/10.1097/RLU.0000000000001101.CrossRefPubMed

23.

Pujara AC, Raad RA, Ponzo F, Wassong C, Babb JS, Moy L, et al. Standardized uptake values from PET/MRI in metastatic breast cancer: an organ-based comparison with PET/CT. Breast J. 2016;22:264–73. https://doi.org/10.1111/tbj.12569.CrossRefPubMedPubMedCentral

24.

Pace L, Nicolai E, Luongo A, Aiello M, Catalano OA, Soricelli A, et al. Comparison of whole-body PET/CT and PET/MRI in breast cancer patients: lesion detection and quantitation of 18F-deoxyglucose uptake in lesions and in normal organ tissues. Eur J Radiol. 2014;83:289–96. https://doi.org/10.1016/j.ejrad.2013.11.002.CrossRefPubMed

25.

Sawicki LM, Grueneisen J, Schaarschmidt BM, Buchbender C, Nagarajah J, Umutlu L, et al. Evaluation of (18)F-FDG PET/MRI, (18)F-FDG PET/CT, MRI, and CT in whole-body staging of recurrent breast cancer. Eur J Radiol. 2016;85:459–65. https://doi.org/10.1016/j.ejrad.2015.12.010.CrossRefPubMed

26.

Segaert I, Mottaghy F, Ceyssens S, De Wever W, Stroobants S, Van Ongeval C, et al. Additional value of PET-CT in staging of clinical stage IIB and III breast cancer. Breast J. 2010;16:617–24. https://doi.org/10.1111/j.1524-4741.2010.00987.x.CrossRefPubMed

27.

Fuster D, Duch J, Paredes P, Velasco M, Munoz M, Santamaria G, et al. Preoperative staging of large primary breast cancer with [18F]fluorodeoxyglucose positron emission tomography/computed tomography compared with conventional imaging procedures. J Clin Oncol. 2008;26:4746–51. https://doi.org/10.1200/JCO.2008.17.1496.CrossRefPubMed

28.

Veronesi U, De Cicco C, Galimberti VE, Fernandez JR, Rotmensz N, Viale G, et al. A comparative study on the value of FDG-PET and sentinel node biopsy to identify occult axillary metastases. Ann Oncol. 2007;18:473–8. https://doi.org/10.1093/annonc/mdl425.CrossRefPubMed

29.

Teixeira SC, Rebolleda JF, Koolen BB, Wesseling J, Jurado RS, Stokkel MP, et al. Evaluation of a hanging-breast PET system for primary tumor visualization in patients with stage I-III breast cancer: comparison with standard PET/CT. AJR Am J Roentgenol. 2016;206:1307–14. https://doi.org/10.2214/AJR.15.15371.CrossRefPubMed

Title: Added value of dedicated axillary hybrid 18F-FDG PET/MRI for improved axillary nodal staging in clinically node-positive breast cancer patients: a feasibility study
Authors: Thiemo J. A. van Nijnatten
B. Goorts
S. Vöö
M. de Boer
L. F. S. Kooreman
E. M. Heuts
J. E. Wildberger
F. M. Mottaghy
M. B. I. Lobbes
M. L. Smidt
Publication date: 01-02-2018
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Nuclear Medicine and Molecular Imaging / Issue 2/2018
Print ISSN: 1619-7070
Electronic ISSN: 1619-7089
DOI: https://doi.org/10.1007/s00259-017-3823-0

At a glance: The STEP trials

Springer Medicine

Added value of dedicated axillary hybrid 18F-FDG PET/MRI for improved axillary nodal staging in clinically node-positive breast cancer patients: a feasibility study

Abstract

Purpose

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 2/2018

The prognostic value of 18F–FDG PET/CT prior to liver transplantation for nonresectable colorectal liver metastases

Repeatability of tumour hypoxia imaging using [18F]EF5 PET/CT in head and neck cancer

Correction to: 18F-NaF PET/CT: EANM procedure guidelines for bone imaging

18F-DOPA PET/CT and 68Ga-DOTANOC PET/CT scans as diagnostic tools in focal congenital hyperinsulinism: a blinded evaluation

68Ga-PSMA-11 PET/CT in primary staging of prostate carcinoma: preliminary results on differences between black and white South-Africans

Invited editorial for the paper by Silvoniemi et al. “Repeatability of tumor hypoxia imaging using [18F]EF5 PET/CT in head and neck cancer.” in this issue of EJNMMI