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Scintimammography with a Hybrid SPECT/CT Imaging System

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Scintimammography with a Hybrid SPECT/CT Imaging System ANTICANCER RESEARCH 27: 557-562 (2007) Scintimammography with a Hybrid SPECT/CT Imaging System ORAZIO SCHILLACI, ROBERTA DANIELI, LUCA FILIPPI, PASQUALE ROMANO, ELSA COSSU, CARLO MANNI and GIOVANNI SIMONETTI Department of Biopathology and Diagnostic Imaging, University "Tor Vergata", Rome, Italy Abstract. Background: Planar scintimammography is useful carcinomas are evident on mammograms, especially in dense for characterizing breast lesions >10 mm. Our aim was to or dysplastic breasts (3); moreover, its specificity and positive evaluate Tc-99m sestamibi scintimammography with a hybrid predictive value are low because it cannot always (SPECT/CT) device for functional anatomical mapping (FAM). differentiate benign lesions from malignant ones (4). The Patients and Methods: Three planar images and a chest drawbacks of mammography have led to the development of SPECT/CT were performed with a hybrid device in 53 patients complementary modalities for breast cancer imaging, with mammographically suspicious lesions. The final including scintimammography, a nuclear medicine technique histopathological diagnosis was obtained after surgery. Results: that uses radiopharmaceuticals to detect malignant breast The planar images were positive in 27 out of 37 carcinomas tumours (5, 6). Scintimammography is conventionally (sensitivity 73%) and the SPECT/CT in 33 (sensitivity 89.2%). performed with planar acquisitions, which have a low The sensitivity of planar imaging and SPECT/CT was 42.9% sensitivity for lesions ≤10 mm (5). Recently, a new imaging and 71.4% in cancers ≤10 mm, and 91.3%, and 100% in device combining a dual-head, variable angle gamma camera cancers >10 mm, respectively. The specificity was 93.8% for with a low-dose X-ray tube has been introduced (7): this both planar and SPECT/CT imaging; accuracy was 79.2% for hybrid gamma camera/CT scanner provides cross-sectional planar scans and 90.6% for SPECT/CT. FAM was useful in X-ray transmission images that facilitate anatomical providing a precise anatomical localisation of the SPECT localisation of radiotracer uptake, because the acquired findings. Conclusion: SPECT/CT scintimammography using a tomoscintigraphic and CT images are co-registered by means hybrid device is able to detect breast cancer, showing a sensitivity of the hardware in the same session (8). higher than that of planar images, especially for small cancers. The aim of this study was to evaluate the usefulness of this new imaging system for functional anatomical mapping Breast cancer is the most common malignancy in women: it (FAM) in patients with suspected breast cancer submitted represents 32% of all invasive tumours in the female to scintimammography with Tc-99m sestamibi, and if FAM population in the U.S.A., and it accounts for 15% of all is able to improve the accuracy of conventional planar women’s cancer deaths. In 2005, the American Cancer Society images in breast cancer diagnosis. estimated 211,240 new cases and 40,410 female deaths from this disease (1). Trends in incidence and mortality show that Patients and Methods there has been a small but steady annual increase in breast carcinoma incidence over the last 30 years, whereas the Fifty-three female patients (age range: 27-78 years) with suspicious mortality rate has declined steadily since the beginning of 1990 breast lesions on mammography were evaluated. The final (1). This improvement is attributed to earlier detection of histopathological diagnosis was obtained in all the cases after surgery. breast cancer using mammographic screening. Each patient gave written informed consent to participate in the study. Patients were injected with 740 MBq of Tc-99m sestamibi Till now, mammography is the best imaging modality for ~ (Bristol-Myers Squibb Pharma, Bruxelles, Belgium) into an the early identification of breast cancer (2). Nevertheless, antecubital vein of the opposite arm to the known mammary lesion. this technique has some limitations: not all breast The labelling and quality control procedures were carried out according to the manufacturer's instructions. All scintigraphic images were acquired using a combined SPECT/CT system (Millenium VG & Hawkeye; General Electric Medical Systems, Correspondence to: Prof. Orazio Schillaci, Viale G. Mazzini 121, Milwaukee, WI, USA) composed of a dual-head, variable angle 00195 Rome, Italy. Tel: +39 06 20902419, Fax: +39 06 37359664, gamma-camera and an X-ray tube with a set of detectors mounted e-mail: [email protected] on opposite sides of the gamma-camera gantry. This system enables the sequential interchangeable acquisition of nuclear medicine and Key Words: Breast cancer, scintimammography, Tc-99m sestamibi, CT images. The CT scanner has a fixed anode oil-cooled X-ray hybrid imaging, SPECT/CT. tube operating at 140 kV and 2.5 mA during the acquisition of each 0250-7005/2007 $2.00+.40 557 ANTICANCER RESEARCH 27: 557-562 (2007) Table I. Histopathological findings. Table II. Overview of the results. Histology Lesion (n) Planar FAM Malignant lesions 37 Sensitivity 73% (27/37) 89.2% (33/37)* Infiltrating ductal carcinoma 29 Mixed ductal and lobular carcinoma 4 Specificity 93.8% (15/16) 93.8% (15/16) Infiltrating lobular carcinoma 3 PPV 96.4% (27/28) 97.1% (33/34) Infiltrating mucinous carcinoma 1 NPV 60% (15/25) 78.9% (15/19) Benign conditions 16 Accuracy 79.2% (42/53 90.6% (48/53)* Fibrocystic disease 8 Fibroadenoma 6 FAM=functional anatomical mapping; PPV=positive predictive value; Papilloma 1 NPV=negative predictive value. Cyst 1 *p<0.05 vs. planar. transverse slice. The X-ray tube and the linear detector array rotate significance of the differences between the sensitivity, specificity together in a fixed geometry at 2.6 revolutions per minute, with the and accuracy of SPECT/CT and planar scintimammography for the acquisition of a single slice in 14 seconds. After completion of the detection of breast cancer. The statistical significance of the first acquisition (transmission or emission), the patient is differences between the sensitivity of the two procedures was automatically repositioned so that the previous 40-cm axial field calculated taking into account overall primary breast cancers and exactly corresponds with the second imaging modality’s 40-cm axial after subdividing the carcinomas according to palpability (palpable field of view. vs. non-palpable) and size (≤10 mm vs. >10 mm). The ¯2 test was The scintigraphic protocol included multiple planar views, used to assess the statistical significance of differences in the starting 10 minutes post-injection, followed by SPECT/CT imaging. sensitivity of SPECT/CT and planar images after subdividing the Three planar scans (128x128 matrix, 10 min/view) were performed: breast cancers according to palpability and size. P-values below two lateral images (left and right) with the patient in the prone 0.05 were considered significant. position with a special cushion that enables the examined breast to hang freely through an opening, very close to the collimator of the Results gamma-camera, and an anterior chest image with the patient in the supine position. SPECT/CT was acquired with the patients in the supine position using these parameters: SPECT over 360Æ (matrix 128x128, 3Æ According to the histopathologic results, the patients were angle steps, 30 sec/frame), followed by CT, obtained by "half-scan" divided into two groups as malignant and benign breast lesions acquisition over 220Æ for each transaxial slice; multiple slices were (Table I). There were 37 cancers (four different histologic performed by moving the table by a slice step before acquiring the types, palpable in 21 cases and non-palpable in 16 cases) and next slice, with the full field of view consisting of 40 slices. 16 benign lesions (four different histologic diagnoses, palpable From the raw data, SPECT images were reconstructed to in 11 cases and non-palpable in 5 cases). According to the produce transaxial slices; coronal and sagittal views were then American Joint Committee on Cancer (AJCC) tumour (T) obtained. Also CT data were reconstructed using the nuclear medicine workstation (eNTEGRA, General Electric Medical pathologic classification, three carcinomas were classified as Systems, Milwaukee, WI, USA) to produce cross-sectional T1a, 11 as T1b, 18 as T1c and five as T2. attenuation images (256x256 matrix) in which each pixel represents SPECT/CT scintimammography detected 33 out of 37 the attenuation of the imaged tissue. The X-ray reconstructed primary breast carcinomas, planar imaging 27/37, and both images were implemented into nuclear medicine. Matching pairs procedures were true-negative in 15/16 benign mammary of emission and transmission were fused and images overlying the lesions. Table II reports the overall sensitivity, specificity, SPECT data on the corresponding anatomic planes were accuracy, positive and negative predictive values of generated. All scintigraphies were evaluated blindly by two experienced SPECT/CT and planar scintimammography, calculated on nuclear medicine physicians (O.S. and R.D.) who did not know the the basis of true-positive, false-negative, true-negative and final diagnosis of the patients, and classified as positive or negative false positive results. for Tc-99m sestamibi focal abnormal accumulation in the breast; SPECT/CT was positive in 1/3 T1a, in 9/11 T1b, in 18/18 disagreements were resolved by consensus, with a third observer T1c and in 5/5 T2 carcinomas, while planar images were (L.F.) as a referee. positive in 0/3, in 6/11, in 16/18 and in 5/5, respectively. When considering palpability, SPECT/CT in all the palpable Statistical analysis. The scintigraphic results were compared to the histopathological findings after surgery, and the sensitivity, cancers and in 12 out of 16 of the non-palpable ones, specificity, accuracy, and positive and negative predictive value whereas planar imaging was positive in 19/21 and in 8/16, were determined. McNemar’s test was used to assess the statistical respectively. SPECT/CT sensitivity values were significantly 558 Schillaci et al: SPECT/CT Scintimammography higher than those of the planar scans both in cancers sized of a North American multi-centre trial involving 673 <10 mm (71.4% vs.
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