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NEW IMAGING MODALITIES IN BREAST CANCER MANAGEMENT

NEW IMAGING MODALITIES IN BREAST CANCER MANAGEMENT. Dr Rachel Boutemy. 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

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NEW IMAGING MODALITIES IN BREAST CANCER MANAGEMENT

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  1. NEW IMAGING MODALITIES IN BREAST CANCER MANAGEMENT Dr Rachel Boutemy

  2. 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

  3. MRI & THERAPY MONITORING 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]

  4. MRI & THERAPY MONITORING 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]

  5. MRI & THERAPY MONITORING PREDICTION OF TUMOR RESPONSE/ MORPHOLOGY Initial morphologic patterns Likelihood of response to treatment Rate of breast conservation Partial or complete response: 77% in pattern 1 >< 25% in pattern 5[Esserman An surg oncol 2001] Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5

  6. MRI & THERAPY MONITORING PREDICTION OF TUMOR RESPONSE/ MORPHOLOGY Volumetric measurements Reduction >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].

  7. MRI & THERAPY MONITORING 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

  8. MRI & THERAPY MONITORING PREDICTION OF TUMOR RESPONSE / FUNCTIONAL H MR Spectroscopy quantify total choline level Adjunct 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…

  9. MRI & THERAPY MONITORING 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…

  10. PET & BREAST CANCER STAGING • Assessment of the metabolic activity of tissue • Limited diagnostic value for detection • Co registration FDG PET & CT : better diagnostic accuracy

  11. PET/CT & BREAST CANCER STAGING 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?

  12. PET & BREAST CANCER STAGING 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

  13. PET & BREAST CANCER STAGING BONE M+ Bone Scinti Blastic M+ PET Lytic and intramedullary M+

  14. PET & BREAST CANCER STAGING BONE M+ & SPECT/CT

  15. PET & BREAST CANCER STAGING 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]

  16. PET & BREAST CANCER STAGING 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]

  17. PET & THERAPY MONITORING 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 %)

  18. PET & THERAPY MONITORING 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…)

  19. AXILLARY NODAL STATUS 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??

  20. AXILLARY NODAL STATUS 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

  21. AXILLARY NODAL STATUS [STAVROS, BREAST ULTRASOUND 2004]

  22. AXILLARY NODAL STATUS 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].

  23. 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

  24. FUTURE ? • MRI: reproducible and comparable protocols (help of the constructors!) • Other imaging modalities : PET mammography,… • Characterization of the lesions

  25. Thanks to Dr Delphine LUYX! From the Nuclear Medecine CAVELL - CHIREC

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