Comprehensive imaging of tumor recurrence in breast cancer patients using whole-body MRI at 1.5 and 3 T compared to FDG–PET–CT
Introduction
Breast cancer is the most frequent malignancy and the most common cause of cancer-related death in women worldwide with approximately 500,000 deaths each year [1]. Approximately, 30% of all patients diagnosed with breast cancer are at risk of developing tumor recurrence at some time within the course of their disease. Therefore, early diagnosis and accurate restaging of recurrent breast cancer is important to define appropriate therapeutic strategies or to identify patients with limited disease who potentially could benefit from curative treatment. Primary staging and follow-up of breast cancer usually is performed with multi-modality imaging approaches using conventional radiographs, ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI), based on changes in density, size or contrast enhancement. However, a sequential imaging approach can be time-intensive and potential false-negative findings may delay appropriate therapy.
It has been reported that whole-body fluorodeoxyglucose (FDG)–positron emission tomography (PET) is of clinical value in the search for breast cancer metastases, especially when suggested by the presence of clinical symptoms or by a progressive increase in biochemical markers [2], [3]. The combination of metabolic data from PET with the detailed anatomical information of multi-slice computed tomography as dual-modality scanners has markedly increased lesion localization and diagnostic accuracy compared to both modalities as standalone applications [4], [5]. Recently, combined PET–CT has been introduced as a whole-body imaging modality for screening of patients with suspicion of recurrent breast cancer, indicating an improved restaging accuracy and possible impact on therapy [5], [6].
MRI, with its lack of ionizing radiation, high soft tissue contrast and spatial resolution is a useful application for tumor detection and staging of malignant disease. A high sensitivity has been reported for the detection of organ metastases, especially for tumors frequently metastasizing to the liver, bone or the brain, like breast cancer [7], [8]. However, different requirements in coil setup, sequence design and slice positioning as well as time-consuming patient repositioning procedures in the past have delayed the realization of WB-MRI as a clinical application. With the introduction of multi-channel whole-body scanners, covering the patient's anatomy from head to toe, MRI has become a promising candidate for whole-body body tumor imaging. Now, dedicated assessment of individual organs with various soft tissue contrast, image orientation, spatial resolution and contrast media dynamics can be combined with whole-body anatomic coverage [9], [10].
Recently, approved clinical multi-channel whole-body MR systems with a field strength of 3 T became available. The potential two-fold gain in SNR at 3 T can be used for either acquisition acceleration or increased spatial resolution, or for a compromise of both, resulting in even shorter total examinations times, increased patient comfort and acceptance. Various study groups have reported an improved diagnostic accuracy and image quality at 3 T for different dedicated organ systems, like functional or morphologic imaging of the brain, vessels and defined musculoskeletal structures [11], [12], [13]. Yet, only few scientific studies have described the use of high-field systems in other parts of the body, including the chest, abdomen or even as whole-body application [14], [15], [16].
The purpose of this study was to compare the diagnostic potential of FDG–PET–CT and WB-MRI in patients with breast cancer and suspicion of tumor recurrence. Additionally, WB-MRI at high field conditions is introduced as a new feasible application within a clinical setting.
Section snippets
Materials and methods
The study included 33 female patients (mean age 55 years, range 24–79 years) with a history of breast cancer, all treated with a primarily curative approach. The patients were referred to our hospital within a time period of 22 months for follow-up with either clinical suspicion of tumor recurrence (n = 9), a conspicuous finding in another imaging modality (n = 14) or newly elevated tumor marker levels (n = 10) (Table 1). All patients were examined consecutively with a dual-modality PET–CT-scanner
Results
Tumor recurrence was found in 20 of 33 patients (61%). Altogether PET–CT and WB-MRI detected 186 lesions classified as malignant and 77 lesions considered benign. Thirteen patients had no visible malignant pathologies and also were negative on follow-up examinations. The correlation between both modalities was 87% (228/263) for all detected lesions. The described lesions were observed within the common FOV of both modalities from the skull base to the proximal femoral bone. All 36 discordant
Discussion
The basic imaging approach in the follow-up of breast cancer supported by the German Cancer Society to date consists of regular mammography and clinical examinations as well as symptom-orientated multi-modal imaging strategies [31]. This procedure by large is based on the assumptions from studies performed in the early 1990s, that an intensified after-care does not necessarily correlate with an increased survival benefit [32], [33]. Unfortunately, this approach mainly comprises modalities with
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