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Breast
Imaging
Special Topics in Screening and Diagnostic Imaging
PET/CT
PET/CT
Regina J. Hooley, MD; Selin Carkaci, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Pathology

        • Diagnostic Checklist

          TERMINOLOGY

          • Abbreviations

            • Positron emission tomography/computed tomography (PET/CT)

          • Definitions

            • Coregistration of PET with CT allows combined functional and anatomic imaging with single scanner
            • Megabecquerel (MBq): Unit of radioactivity = 10⁶ disintegrations per second
            • 1 millicurie (mCi) = 3.7 x 10⁷ disintegrations/sec = 37 MBq
            • Standardized uptake value (SUV): Activity concentration in tissue (MBq/kg)/[injected activity (MBq)/ body weight (kg)]
              • Most common parameter used to measure tracer accumulation activity concentration in tissue
              • To measure SUV, a 2D or 3D region of interest (ROI) is positioned centrally within a target (i.e., tumor)
              • 2 common ways of reporting SUV
                • SUVmean: Incorporates information from multiple voxels, making it less sensitive to image noise
                  • Sensitive to ROI definition and subject to intra-/interobserver variability
                • SUVmax: Highest voxel value within ROI
                  • Independent of ROI definition if included in ROI, but more susceptible to noise
                  • Most commonly used because it is less observer-dependent and more reproducible than SUVmean

          IMAGING

          • Physiology

            • Guidelines in Imaging Breast Cancer

              • Breast Cancer Detection

                • Locoregional Staging

                  • Distant Metastasis

                    • Restaging/Recurrence

                      • Treatment Response

                        • Inflammatory Breast Cancer

                          PATHOLOGY

                          • Pathology-Related Imaging Issues

                            DIAGNOSTIC CHECKLIST

                            • Consider

                              • Image Interpretation Pearls

                                Selected References

                                1. Lee H et al: Predicting response to neoadjuvant chemotherapy in patients with breast cancer: combined statistical modeling using clinicopathological factors and FDG PET/CT texture parameters. Clin Nucl Med. 44(1):21-29, 2019
                                2. Chen W et al: Quantitative assessment of metabolic tumor burden in molecular subtypes of primary breast cancer with FDG PET/CT. Diagn Interv Radiol. 24(6):336-41, 2018
                                3. Ellmann S et al: Prediction of early metastatic disease in experimental breast cancer bone metastasis by combining PET/CT and MRI parameters to a Model-Averaged Neural Network. Bone. 120:254-61, 2018
                                4. Henry KE et al: Clinical potential of human epidermal growth factor receptor 2 and human epidermal growth factor receptor 3 imaging in breast cancer. PET Clin. 13(3):423-35, 2018
                                5. Kurland BF et al: Heterogeneity in metastatic breast cancer 18F-fluoroestradiol uptake: Clinically actionable, biologically illuminating? J Nucl Med. 59(8):1210-11, 2018
                                6. Nienhuis HH et al: 18F-Fluoroestradiol Tumor Uptake Is Heterogeneous and Influenced by Site of Metastasis in Breast Cancer Patients. J Nucl Med. 59(8):1212-18, 2018
                                7. Salem K et al: 18F-16α-17β-Fluoroestradiol Binding Specificity in Estrogen Receptor-Positive Breast Cancer. Radiology. 286(3):856-64, 2018
                                8. Groheux D et al: 18FDG-PET/CT for predicting the outcome in ER+/HER2- breast cancer patients: comparison of clinicopathological parameters and PET image-derived indices including tumor texture analysis. Breast Cancer Res. 19(1):3, 2017
                                9. Melsaether A et al: Breast PET/MR imaging. Radiol Clin North Am. 55(3):579-89, 2017
                                10. Song BI et al: Predictive value of 18F-FDG PET/CT for axillary lymph node metastasis in invasive ductal breast cancer. Ann Surg Oncol. 24(8):2174-81, 2017
                                11. Ulaner GA et al: 89Zr-Trastuzumab PET/CT for Detection of Human Epidermal Growth Factor Receptor 2-Positive Metastases in Patients With Human Epidermal Growth Factor Receptor 2-Negative Primary Breast Cancer. Clin Nucl Med. 42(12):912-17, 2017
                                12. Groheux D et al: ¹⁸F-FDG PET/CT for Staging and Restaging of Breast Cancer. J Nucl Med. 57 Suppl 1:17S-26S, 2016
                                13. Groheux D et al: Prognostic impact of 18F-FDG PET/CT staging and of pathological response to neoadjuvant chemotherapy in triple-negative breast cancer. Eur J Nucl Med Mol Imaging. 42(3):377-85, 2015
                                14. Hogan MP et al: Comparison of 18F-FDG PET/CT for Systemic Staging of Newly Diagnosed Invasive Lobular Carcinoma Versus Invasive Ductal Carcinoma. J Nucl Med. 56(11):1674-80, 2015
                                15. Kaushik A et al: Estimation of radiation dose to patients from (18) FDG whole body PET/CT investigations using dynamic PET scan protocol. Indian J Med Res. 142(6):721-31, 2015
                                16. Shin KM et al: Incidental Breast Lesions Identified by (18)F-FDG PET/CT: Which Clinical Variables Differentiate between Benign and Malignant Breast Lesions? J Breast Cancer. 18(1):73-9, 2015
                                17. Kalinyak JE et al: Breast cancer detection using high-resolution breast PET compared to whole-body PET or PET/CT. Eur J Nucl Med Mol Imaging. 41(2):260-75, 2014
                                18. Carkaci S et al: (18)F-FDG PET/CT predicts survival in patients with inflammatory breast cancer undergoing neoadjuvant chemotherapy. Eur J Nucl Med Mol Imaging. Epub ahead of print, 2013
                                19. Groheux D et al: 18F-FDG PET/CT in staging patients with locally advanced or inflammatory breast cancer: comparison to conventional staging. J Nucl Med. 54(1):5-11, 2013
                                20. Groheux D et al: Performance of FDG PET/CT in the clinical management of breast cancer. Radiology. 266(2):388-405, 2013
                                21. Kaushik A et al: Estimation of patient dose in (18)F-FDG and (18)F-FDOPA PET/CT examinations. J Cancer Res Ther. 9(3):477-83, 2013
                                22. Rong J et al: Comparison of (18)FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol. 22(2):86-91, 2013
                                23. Adejolu M et al: False-positive lesions mimicking breast cancer on FDG PET and PET/CT. AJR Am J Roentgenol. 198(3):W304-14, 2012
                                24. Cooper KL et al: Positron emission tomography (PET) for assessment of axillary lymph node status in early breast cancer: A systematic review and meta-analysis. Eur J Surg Oncol. 37(3):187-98, 2011
                                25. Long NM et al: Causes and imaging features of false positives and false negatives on F-PET/CT in oncologic imaging. Insights Imaging. 2(6):679-698, 2011
                                26. Tateishi U et al: Neoadjuvant chemotherapy in breast cancer: prediction of pathologic response with PET/CT and dynamic contrast-enhanced MR imaging--prospective assessment. Radiology. 263(1):53-63, 2012
                                27. Adams MC et al: A systematic review of the factors affecting accuracy of SUV measurements. AJR Am J Roentgenol. 195(2):310-20, 2010
                                28. Carkaci S et al: Retrospective study of 18F-FDG PET/CT in the diagnosis of inflammatory breast cancer: preliminary data. J Nucl Med. 50(2):231-8, 2009
                                29. Lavayssière R et al: Positron Emission Tomography (PET) and breast cancer in clinical practice. Eur J Radiol. 69(1):50-8, 2009
                                30. Avril N et al: F-18 fluorodeoxyglucose-positron emission tomography imaging for primary breast cancer and loco-regional staging. Radiol Clin North Am. 45(4):645-57, vi, 2007
                                31. Rosen EL et al: FDG PET, PET/CT, and breast cancer imaging. Radiographics. 27 Suppl 1:S215-29, 2007
                                32. Avril N et al: Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol. 18(20):3495-502, 2000
                                33. Smith RF et al: Characterization of anaerobic diphtheroids. Health Lab Sci. 5(2):95-9, 1968
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Imaging

                                    • Pathology

                                      • Diagnostic Checklist

                                        TERMINOLOGY

                                        • Abbreviations

                                          • Positron emission tomography/computed tomography (PET/CT)

                                        • Definitions

                                          • Coregistration of PET with CT allows combined functional and anatomic imaging with single scanner
                                          • Megabecquerel (MBq): Unit of radioactivity = 10⁶ disintegrations per second
                                          • 1 millicurie (mCi) = 3.7 x 10⁷ disintegrations/sec = 37 MBq
                                          • Standardized uptake value (SUV): Activity concentration in tissue (MBq/kg)/[injected activity (MBq)/ body weight (kg)]
                                            • Most common parameter used to measure tracer accumulation activity concentration in tissue
                                            • To measure SUV, a 2D or 3D region of interest (ROI) is positioned centrally within a target (i.e., tumor)
                                            • 2 common ways of reporting SUV
                                              • SUVmean: Incorporates information from multiple voxels, making it less sensitive to image noise
                                                • Sensitive to ROI definition and subject to intra-/interobserver variability
                                              • SUVmax: Highest voxel value within ROI
                                                • Independent of ROI definition if included in ROI, but more susceptible to noise
                                                • Most commonly used because it is less observer-dependent and more reproducible than SUVmean

                                        IMAGING

                                        • Physiology

                                          • Guidelines in Imaging Breast Cancer

                                            • Breast Cancer Detection

                                              • Locoregional Staging

                                                • Distant Metastasis

                                                  • Restaging/Recurrence

                                                    • Treatment Response

                                                      • Inflammatory Breast Cancer

                                                        PATHOLOGY

                                                        • Pathology-Related Imaging Issues

                                                          DIAGNOSTIC CHECKLIST

                                                          • Consider

                                                            • Image Interpretation Pearls

                                                              Selected References

                                                              1. Lee H et al: Predicting response to neoadjuvant chemotherapy in patients with breast cancer: combined statistical modeling using clinicopathological factors and FDG PET/CT texture parameters. Clin Nucl Med. 44(1):21-29, 2019
                                                              2. Chen W et al: Quantitative assessment of metabolic tumor burden in molecular subtypes of primary breast cancer with FDG PET/CT. Diagn Interv Radiol. 24(6):336-41, 2018
                                                              3. Ellmann S et al: Prediction of early metastatic disease in experimental breast cancer bone metastasis by combining PET/CT and MRI parameters to a Model-Averaged Neural Network. Bone. 120:254-61, 2018
                                                              4. Henry KE et al: Clinical potential of human epidermal growth factor receptor 2 and human epidermal growth factor receptor 3 imaging in breast cancer. PET Clin. 13(3):423-35, 2018
                                                              5. Kurland BF et al: Heterogeneity in metastatic breast cancer 18F-fluoroestradiol uptake: Clinically actionable, biologically illuminating? J Nucl Med. 59(8):1210-11, 2018
                                                              6. Nienhuis HH et al: 18F-Fluoroestradiol Tumor Uptake Is Heterogeneous and Influenced by Site of Metastasis in Breast Cancer Patients. J Nucl Med. 59(8):1212-18, 2018
                                                              7. Salem K et al: 18F-16α-17β-Fluoroestradiol Binding Specificity in Estrogen Receptor-Positive Breast Cancer. Radiology. 286(3):856-64, 2018
                                                              8. Groheux D et al: 18FDG-PET/CT for predicting the outcome in ER+/HER2- breast cancer patients: comparison of clinicopathological parameters and PET image-derived indices including tumor texture analysis. Breast Cancer Res. 19(1):3, 2017
                                                              9. Melsaether A et al: Breast PET/MR imaging. Radiol Clin North Am. 55(3):579-89, 2017
                                                              10. Song BI et al: Predictive value of 18F-FDG PET/CT for axillary lymph node metastasis in invasive ductal breast cancer. Ann Surg Oncol. 24(8):2174-81, 2017
                                                              11. Ulaner GA et al: 89Zr-Trastuzumab PET/CT for Detection of Human Epidermal Growth Factor Receptor 2-Positive Metastases in Patients With Human Epidermal Growth Factor Receptor 2-Negative Primary Breast Cancer. Clin Nucl Med. 42(12):912-17, 2017
                                                              12. Groheux D et al: ¹⁸F-FDG PET/CT for Staging and Restaging of Breast Cancer. J Nucl Med. 57 Suppl 1:17S-26S, 2016
                                                              13. Groheux D et al: Prognostic impact of 18F-FDG PET/CT staging and of pathological response to neoadjuvant chemotherapy in triple-negative breast cancer. Eur J Nucl Med Mol Imaging. 42(3):377-85, 2015
                                                              14. Hogan MP et al: Comparison of 18F-FDG PET/CT for Systemic Staging of Newly Diagnosed Invasive Lobular Carcinoma Versus Invasive Ductal Carcinoma. J Nucl Med. 56(11):1674-80, 2015
                                                              15. Kaushik A et al: Estimation of radiation dose to patients from (18) FDG whole body PET/CT investigations using dynamic PET scan protocol. Indian J Med Res. 142(6):721-31, 2015
                                                              16. Shin KM et al: Incidental Breast Lesions Identified by (18)F-FDG PET/CT: Which Clinical Variables Differentiate between Benign and Malignant Breast Lesions? J Breast Cancer. 18(1):73-9, 2015
                                                              17. Kalinyak JE et al: Breast cancer detection using high-resolution breast PET compared to whole-body PET or PET/CT. Eur J Nucl Med Mol Imaging. 41(2):260-75, 2014
                                                              18. Carkaci S et al: (18)F-FDG PET/CT predicts survival in patients with inflammatory breast cancer undergoing neoadjuvant chemotherapy. Eur J Nucl Med Mol Imaging. Epub ahead of print, 2013
                                                              19. Groheux D et al: 18F-FDG PET/CT in staging patients with locally advanced or inflammatory breast cancer: comparison to conventional staging. J Nucl Med. 54(1):5-11, 2013
                                                              20. Groheux D et al: Performance of FDG PET/CT in the clinical management of breast cancer. Radiology. 266(2):388-405, 2013
                                                              21. Kaushik A et al: Estimation of patient dose in (18)F-FDG and (18)F-FDOPA PET/CT examinations. J Cancer Res Ther. 9(3):477-83, 2013
                                                              22. Rong J et al: Comparison of (18)FDG PET-CT and bone scintigraphy for detection of bone metastases in breast cancer patients. A meta-analysis. Surg Oncol. 22(2):86-91, 2013
                                                              23. Adejolu M et al: False-positive lesions mimicking breast cancer on FDG PET and PET/CT. AJR Am J Roentgenol. 198(3):W304-14, 2012
                                                              24. Cooper KL et al: Positron emission tomography (PET) for assessment of axillary lymph node status in early breast cancer: A systematic review and meta-analysis. Eur J Surg Oncol. 37(3):187-98, 2011
                                                              25. Long NM et al: Causes and imaging features of false positives and false negatives on F-PET/CT in oncologic imaging. Insights Imaging. 2(6):679-698, 2011
                                                              26. Tateishi U et al: Neoadjuvant chemotherapy in breast cancer: prediction of pathologic response with PET/CT and dynamic contrast-enhanced MR imaging--prospective assessment. Radiology. 263(1):53-63, 2012
                                                              27. Adams MC et al: A systematic review of the factors affecting accuracy of SUV measurements. AJR Am J Roentgenol. 195(2):310-20, 2010
                                                              28. Carkaci S et al: Retrospective study of 18F-FDG PET/CT in the diagnosis of inflammatory breast cancer: preliminary data. J Nucl Med. 50(2):231-8, 2009
                                                              29. Lavayssière R et al: Positron Emission Tomography (PET) and breast cancer in clinical practice. Eur J Radiol. 69(1):50-8, 2009
                                                              30. Avril N et al: F-18 fluorodeoxyglucose-positron emission tomography imaging for primary breast cancer and loco-regional staging. Radiol Clin North Am. 45(4):645-57, vi, 2007
                                                              31. Rosen EL et al: FDG PET, PET/CT, and breast cancer imaging. Radiographics. 27 Suppl 1:S215-29, 2007
                                                              32. Avril N et al: Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol. 18(20):3495-502, 2000
                                                              33. Smith RF et al: Characterization of anaerobic diphtheroids. Health Lab Sci. 5(2):95-9, 1968