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Breast
Imaging
Special Topics in Screening and Diagnostic Imaging
Dedicated Breast PET (PEM)
Dedicated Breast PET (PEM)
Wendie A. Berg, MD, PhD, FACR, FSBI
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KEY FACTS

  • Terminology

    • Imaging

      TERMINOLOGY

      • Definitions

        • Principles of PET imaging
          • F-18 fluorodeoxyglucose (FDG) is taken up by glucose transporter (substrate for hexokinase), converted to FDG-6-phosphate, and trapped in cells
          • Positrons emitted with decay of radiotracer (e.g., F-18) hit electrons → two 511 keV gamma photons emitted at 180° from each other
            • Requires shielding of room, radiation safety
          • Cameras detect coincident gamma rays to create image
          • Functional imaging of metabolic activity
        • In-plane resolution 1.8 mm for all systems vs. ~ 6 mm for whole-body PET
        • Positron emission mammography (PEM): Dedicated device using breast stabilization → 12 tomographic "slice" images of breast
          • Reduced z-axis resolution of ~ 6 mm with PEM due to planar detectors and limited angle reconstruction; other systems use ring detectors and have < 2-mm resolution in all planes
        • Mammi-PET: Prone system with ring of detectors which rotate around breast; true PET
        • El Mammo: O-scanner prone position or C-PEM with patient semi-prone leaning into scanner with opening for arm
        • Half-life: Time required for 1/2 of nuclei of specific isotopic species to undergo radioactive decay
          • F-18: 110 minute half-life; positron emitter
        • Millicurie (mCi) = 3.7 x 10⁷ disintegrations per second [where 1 disintegration per second = 1 becquerel (Bq)]
        • Standardized uptake value (SUV) in whole-body PET: Tissue activity in mCi/mL divided by [injected FDG dose in mCi divided by body weight in kg]
        • PUV (PEM uptake value) max = maximum voxel uptake in region of interest on single PEM slice
        • LTB (lesion-to-background) ratio = ratio of maximum lesion uptake (PUV) to mean background uptake

      IMAGING

      • Anatomy-Based Imaging Issues

        • Interpretive Criteria

          • Indications

            • New Horizons

              Selected References

              1. Narayanan D and Berg WA: Dedicated breast gamma camera imaging and breast PET: Current status and future directions. PET Clin N Am. 2018
              2. Narayanan D and Berg WA: Use of breast-specific PET scanners and comparison with MR imaging. Magn Reson Imaging Clin N Am. 26(2):265-272, 2018
              3. Teixeira SC 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. 206(6):1307-14, 2016
              4. Yamamoto Y et al: A preliminary report of breast cancer screening by positron emission mammography. Ann Nucl Med. 30(2):130-7, 2016
              5. Caldarella C et al: Diagnostic performance of dedicated positron emission mammography using fluorine-18-fluorodeoxyglucose in women with suspicious breast lesions: a meta-analysis. Clin Breast Cancer. 14(4):241-8, 2014
              6. Koo HR et al: Background ¹⁸F-FDG uptake in positron emission mammography (PEM): correlation with mammographic density and background parenchymal enhancement in breast MRI. Eur J Radiol. 82(10):1738-42, 2013
              7. Berg WA et al: Comparative effectiveness of positron emission mammography and MRI in the contralateral breast of women with newly diagnosed breast cancer. AJR Am J Roentgenol. 198(1):219-32, 2012
              8. Eo JS et al: Imaging sensitivity of dedicated positron emission mammography in relation to tumor size. Breast. 21(1):66-71, 2012
              9. Iima M et al: Clinical performance of 2 dedicated PET scanners for breast imaging: initial evaluation. J Nucl Med. 53(10):1534-42, 2012
              10. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
              11. Kalinyak JE et al: PET-guided breast biopsy. Breast J. 17(2):143-51, 2011
              12. Narayanan D et al: Interpretation of positron emission mammography and MRI by experienced breast imaging radiologists: performance and observer reproducibility. AJR Am J Roentgenol. 196(4):971-81, 2011
              13. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196(4):956-70, 2011
              14. Schilling K et al: Positron emission mammography in breast cancer presurgical planning: comparisons with magnetic resonance imaging. Eur J Nucl Med Mol Imaging. 38(1):23-36, 2011
              15. Hendrick RE: Radiation doses and cancer risks from breast imaging studies. Radiology. 257(1):246-53, 2010
              16. MacDonald L et al: Clinical imaging characteristics of the positron emission mammography camera: PEM Flex Solo II. J Nucl Med. 50(10):1666-75, 2009
              17. Adler LP et al: Quantitative improvement in breast lesion detectability on delayed images using high resolution positron emission mammography. J Nuc Med. 48 (suppl 2):369P, 2007
              18. Berg WA et al: High-resolution fluorodeoxyglucose positron emission tomography with compression ("positron emission mammography") is highly accurate in depicting primary breast cancer. Breast J. 12(4):309-23, 2006
              19. Tafra L et al: Pilot clinical trial of 18F-fluorodeoxyglucose positron-emission mammography in the surgical management of breast cancer. Am J Surg. 190(4):628-32, 2005
              20. Vranjesevic D et al: Relationship between 18F-FDG uptake and breast density in women with normal breast tissue. J Nucl Med. 44(8):1238-42, 2003
              Related Anatomy
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              Related Differential Diagnoses
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              References
              Tables

              Tables

              KEY FACTS

              • Terminology

                • Imaging

                  TERMINOLOGY

                  • Definitions

                    • Principles of PET imaging
                      • F-18 fluorodeoxyglucose (FDG) is taken up by glucose transporter (substrate for hexokinase), converted to FDG-6-phosphate, and trapped in cells
                      • Positrons emitted with decay of radiotracer (e.g., F-18) hit electrons → two 511 keV gamma photons emitted at 180° from each other
                        • Requires shielding of room, radiation safety
                      • Cameras detect coincident gamma rays to create image
                      • Functional imaging of metabolic activity
                    • In-plane resolution 1.8 mm for all systems vs. ~ 6 mm for whole-body PET
                    • Positron emission mammography (PEM): Dedicated device using breast stabilization → 12 tomographic "slice" images of breast
                      • Reduced z-axis resolution of ~ 6 mm with PEM due to planar detectors and limited angle reconstruction; other systems use ring detectors and have < 2-mm resolution in all planes
                    • Mammi-PET: Prone system with ring of detectors which rotate around breast; true PET
                    • El Mammo: O-scanner prone position or C-PEM with patient semi-prone leaning into scanner with opening for arm
                    • Half-life: Time required for 1/2 of nuclei of specific isotopic species to undergo radioactive decay
                      • F-18: 110 minute half-life; positron emitter
                    • Millicurie (mCi) = 3.7 x 10⁷ disintegrations per second [where 1 disintegration per second = 1 becquerel (Bq)]
                    • Standardized uptake value (SUV) in whole-body PET: Tissue activity in mCi/mL divided by [injected FDG dose in mCi divided by body weight in kg]
                    • PUV (PEM uptake value) max = maximum voxel uptake in region of interest on single PEM slice
                    • LTB (lesion-to-background) ratio = ratio of maximum lesion uptake (PUV) to mean background uptake

                  IMAGING

                  • Anatomy-Based Imaging Issues

                    • Interpretive Criteria

                      • Indications

                        • New Horizons

                          Selected References

                          1. Narayanan D and Berg WA: Dedicated breast gamma camera imaging and breast PET: Current status and future directions. PET Clin N Am. 2018
                          2. Narayanan D and Berg WA: Use of breast-specific PET scanners and comparison with MR imaging. Magn Reson Imaging Clin N Am. 26(2):265-272, 2018
                          3. Teixeira SC 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. 206(6):1307-14, 2016
                          4. Yamamoto Y et al: A preliminary report of breast cancer screening by positron emission mammography. Ann Nucl Med. 30(2):130-7, 2016
                          5. Caldarella C et al: Diagnostic performance of dedicated positron emission mammography using fluorine-18-fluorodeoxyglucose in women with suspicious breast lesions: a meta-analysis. Clin Breast Cancer. 14(4):241-8, 2014
                          6. Koo HR et al: Background ¹⁸F-FDG uptake in positron emission mammography (PEM): correlation with mammographic density and background parenchymal enhancement in breast MRI. Eur J Radiol. 82(10):1738-42, 2013
                          7. Berg WA et al: Comparative effectiveness of positron emission mammography and MRI in the contralateral breast of women with newly diagnosed breast cancer. AJR Am J Roentgenol. 198(1):219-32, 2012
                          8. Eo JS et al: Imaging sensitivity of dedicated positron emission mammography in relation to tumor size. Breast. 21(1):66-71, 2012
                          9. Iima M et al: Clinical performance of 2 dedicated PET scanners for breast imaging: initial evaluation. J Nucl Med. 53(10):1534-42, 2012
                          10. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
                          11. Kalinyak JE et al: PET-guided breast biopsy. Breast J. 17(2):143-51, 2011
                          12. Narayanan D et al: Interpretation of positron emission mammography and MRI by experienced breast imaging radiologists: performance and observer reproducibility. AJR Am J Roentgenol. 196(4):971-81, 2011
                          13. Narayanan D et al: Interpretation of positron emission mammography: feature analysis and rates of malignancy. AJR Am J Roentgenol. 196(4):956-70, 2011
                          14. Schilling K et al: Positron emission mammography in breast cancer presurgical planning: comparisons with magnetic resonance imaging. Eur J Nucl Med Mol Imaging. 38(1):23-36, 2011
                          15. Hendrick RE: Radiation doses and cancer risks from breast imaging studies. Radiology. 257(1):246-53, 2010
                          16. MacDonald L et al: Clinical imaging characteristics of the positron emission mammography camera: PEM Flex Solo II. J Nucl Med. 50(10):1666-75, 2009
                          17. Adler LP et al: Quantitative improvement in breast lesion detectability on delayed images using high resolution positron emission mammography. J Nuc Med. 48 (suppl 2):369P, 2007
                          18. Berg WA et al: High-resolution fluorodeoxyglucose positron emission tomography with compression ("positron emission mammography") is highly accurate in depicting primary breast cancer. Breast J. 12(4):309-23, 2006
                          19. Tafra L et al: Pilot clinical trial of 18F-fluorodeoxyglucose positron-emission mammography in the surgical management of breast cancer. Am J Surg. 190(4):628-32, 2005
                          20. Vranjesevic D et al: Relationship between 18F-FDG uptake and breast density in women with normal breast tissue. J Nucl Med. 44(8):1238-42, 2003