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99M-Tc-MDP-Scintimammography in the Evaluation of Breast Masses Or Tumor Angiogenesis

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99M-Tc-MDP-Scintimammography in the Evaluation of Breast Masses Or Tumor Angiogenesis ANTICANCER RESEARCH 24: 1999-2006 (2004) 99m-Tc-MDP-Scintimammography in the Evaluation of Breast Masses or Tumor Angiogenesis NAZIM S. TURHAL1*, FAYSAL DANE1*, FUAT DEDE2, MAHMUT GUMUS1, P. FULDEN YUMUK1, FULYA CAKALAGAOGLU3, DILARA SAVCI3, MUNIRE KARAMAN5, BAHADIR GULLUOGLU4 and H.TURGUT TUROGLU2 Departments of 1Internal Medicine, Division of Oncology, 2Nuclear Medicine, 3Pathology and 4General Surgery, Marmara University Hospital; 5Department of General Surgery, Haydarpasa Teaching and Research Hospital, Turkey Abstract. Background: Vascular endothelial growth factor breast cancer (4,5). Thus, a large number of patients undergo (VEGF) is a prognostic factor in breast cancer. One of the a confirmatory surgical biopsy meaning that many unnecessary mechanisms of extra-skeletal uptake of Tc-99m- biopsies are taken from patients with benign lesions (6). The methylenediphosphonate (MDP) is suggested to be tumor BIRADS is a quality-assurance tool devised for the vascularity. We studied the correlation between MDP uptake and standardization of mammographic reporting to reduce VEGF and compared the diagnostic accuracy of mammography confusion in breast imaging interpretations and facilitate versus MDP-scintimammography(MDP-S). Materials and outcome monitoring (7) (Table I). For lesions in BIRADS Methods: Fifty-four patients with suspicion of breast cancer were category 4 or 5, management options include needle evaluated. Breast images were collected 5-10 minutes after localization with excision or image-guided breast biopsy. injection of Tc-99m-MDP prior to biopsy. Tissue slides were Because most mammographic abnormalities are benign, stained using a rabbit-polyclonal anti-VEGF. Results: MDP-S surgical biopsies subject patients to the small but real risk of showed a diagnostic accuracy of 83.3% in BIRADS category 4 discomfort and cosmetic deformity, potentially with no real lesions. Four out of 23 benign lesions were false-positive. The benefit (8). Thus, a wide spectrum of noninvasive imaging tumor to background (TM/BG) ratio of early images of MDP-S modalities has been proposed to overcome the limitations was correlated with VEGF staining (p: 0.014) and with tumor size inherent in mammography. These include morphological (p: 0.006). Conclusion: Early images of Tc-99m-MDP-S may (ultrasound, magnetic resonance) or functional imaging satisfactorily identify cancers with increased neovascularization. modalities, including radionuclide-based techniques. MDP-S seems to be an accurate imaging modality, especially in Breast scintigraphy using different radiopharmaceuticals has BIRADS category 4 lesions. been found to be a promising technique in the diagnosis of cancer (9-12). Tc-99m-methylenediphosphonate scintimammo- Breast cancer is the leading cause of cancer among women graphy (MDP-S) with early imaging after intravenous injection worldwide (1). Declines in breast cancer mortality rates in has demonstrated significantly improved results in the United States, Canada and Europe have been associated differentiating malignant tumors from benign lesions (10,11). with improvements in effective adjuvant therapy and breast Several mechanisms have been described to explain the extra cancer screening (2, 3). skeletal uptake of Tc-99m-methylenediphosphonate (MDP) Mammography is particularly useful in detecting breast including tumor vascularity, inflammation, local pH factor, abnormalities, but has a relatively low specificity in diagnosing altered calcium metabolism, hormonal influence and cell wall damage (13-15). Vascular endothelial growth factor (VEGF), also known as vascular permeability factor, is a potent and widely *The first two authors contributed equally to this project. distributed angiogenic peptide (16). This growth factor is a dimeric 34-42 kd glycosylated basic protein, with moderate Correspondence to: Nazim S. Turhal, M.D., Plaj Yolu Sk. 25/16 affinity for heparin, encoded in four molecular isoforms Caddebostan, 81080 Istanbul, Turkey. Tel: +90 216 4312760, Fax: +90 216 3275181, e-mail: [email protected] (17). Expression of VEGF may be induced by several factors: hypoxia, altered tumor suppressor genes and also Key Words: Breast cancer, mammography, technetium Tc-99m- certain cytokines such as interleukin1‚, IL-6, oncogenes, medronate, VEGF. growth factors and hormones (18). VEGF expression is 0250-7005/2004 $2.00+.40 1999 ANTICANCER RESEARCH 24: 1999-2006 (2004) Table I. BIRADS classification of mammographic abnormalities (ref 8). MDP-S was performed within one week of mammography using a single head gamma camera (GE Medical Systems) fitted to a low Category Assessment Recommendation energy high-resolution collimator. The matrix size was 256x256 pixel; the photopeak was centered at 140 keV with a symmetrical 20% 1 Negative Routine screening window. The patient was positioned on the gamma camera table in 2 Benign finding Routine screening such a manner that the breast to be imaged was freely suspended. A 3 Probably benign Short interval follow-up to kit preparation (Medrocis, CIS Bio International, France) of Tc-99m- finding establish stability MDP was used and 20 mCi of the radiopharmaceutical was injected 4 Suspicious Not characteristic, but intravenously into the arm contralateral to the breast lesion. Using a abnormality definite probability of special scintimammography table with semicircular apertures, multiple malignancy; consider biopsy planar images in the anterior views in the supine position with arms 5 Highly suggestive High probability of cancer; raised and both lateral views in prone position were acquired at 5-10 of malignancy appropriate action minutes following the intravenous injection of Tc-99m-MDP. An should be taken additional anterior image with the marker placed on the breast mass was also obtained after the first anterior scan was completed. Findings were interpreted by two nuclear medicine physicians as positive or negative according to the presence or absence of foci of increased MDP uptake over background in either breast, without reference to patient history or clinical findings. Tumor to background (TM/BG) present in approximately half of ductal carcinoma in situ ratios were calculated only for patients with focal uptake. and in the majority of invasive breast cancers. This Formalin-fixed, paraffin-embedded breast cancer tissue sections production is significantly associated with high intratumoral were cut, mounted on poly-L-lysine-coated slides, deparaffinized in microvessel density and cancer prognosis (19, 20). xylene and rehydrated in graded alcohol. Slides were stained using The prognostic yield of MDP uptake is not well known. rabbit polyclonal VEGF antibody (VEGF 121, 165, 189, 206, We intended to compare the diagnostic accuracy of BioGenex, San Ramon, CA, USA) for vessel count. Sections were blocked for endogenous peroxidase activity with hydrogen peroxide mammography and MDP-S, and then to study the and antibody immunodetection was investigated with an correlation between MDP uptake and VEGF staining in a immunoperoxidase technique using rabbit polyclonal anti-VEGF. group of patients scheduled for breast biopsies at Marmara Slides were counterstained with Mayer’s haematoxylin. To check the University Hospital in Istanbul, Turkey. quality of the immunohistochemical staining method, ten cases of benign breast lesion and intact breast specimens in all malignant Materials and Methods cases were used as controls. Since 4 of these 10 benign lesions had false-positive MDP uptake, they were chosen as controls specifically. Areas of invasive tumor containing the greatest numbers of Fifty-four eligible female patients were evaluated prospectively. capillaries and small venules (areas of most intense neovas- Patient selection criteria were: age more than 18 years, clinical culariazation), which most frequently occurred at the margins of the enlargement of a palpable mass lesion with BIRADS category 1-3 carcinoma, were examined by light microscopy and were found by and BIRADS category 4 or 5 mammographic lesions of any size. scanning the tumor sections at low power (1x40 and 1x100). Only Lactation, pregnancy, hypoplasic breast and prior history of breast tumors that had good quality staining of microvessels with the cancer during the previous 2 years or prior biopsy on ipsilateral immunoperoxidase technique were evaluated in this study. Samples breast were accepted as exclusion criteria. The protocol was of 3 malignant tumors and 1 MDP uptake-positive benign lesion were approved by the Ethical Committee of Marmara University excluded from the study because of inadequate staining. Medical Faculty, and informed consent was signed by each patient. After the areas of highest neovascularization had been identified, The mean age of the patients was 53.37 ± 13.1 years. all microvessels were counted on a 1x400 field and, according to Only one of the patients had a prior history of breast cancer. their staining density, cases were scored as VEGF (3+) when Her breast cancer presented 3 years previously with a mass lesion cytoplasmic staining in all tumor tissue was strong and diffuse, (2+) in the contra-lateral breast. Physical examination of the breasts was when staining was moderate, (1+) when cytoplasmic staining was done by an experienced breast surgeon. The decision to perform a weak or focal, and negative when no staining was present. The breast biopsy was made by either the breast surgeon or, in the case VEGF immunoreactivity of the malignant lesions is illustrated in of a non-palpable lesion,
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