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Revista Imágenes 04 Update article María Victoria Velázquez Abstract Resumen In this article, the author makes a description of the different forms En este artículo, el autor realiza una descripción de las diferentes that constitute the set of tests with molecular type images that are modalidades que constituyen el conjunto de exámenes con imáge - currently available for the study of the mammary gland. Indeed, nes de tipo moleculares que se encuentran disponibles actualmente molecular studies of the breast is becoming very useful alternative para el estudio de la glándula mamaria. En efecto, los estudios mo - for the evaluation of the primary tumor and metastatic disease. Bre - leculares de la mama se están convirtiendo en alternativas muy úti - ast Specific Scintigraphy Image (BSGI), Molecular Breast Imaging les para la evaluación de la enfermedad tumoral primaria y (MBI), Positron Emission Tomography (PET) and Positron Emis - metastásica. La Gammagrafía Específica de Mama (BSGI), las imá - sion Mammography (PEM), constitute the arsenal of studies sho - genes moleculares de la Mama (MBI), la Tomografía con Emisión wing tumor metabolic activity by uptake of a radiopharmaco. The de Positrones y la Mamografía con Emisión de Positrones (PEM), isotope is absorbed by all cells in the body and is trapped by the tumor constituyen el arsenal de estudios que revelan la actividad metabó - cells which emit gamma rays that are themselves picked up by the lica del tumor por la captación de un radiofármaco. El isótopo se gamma camera and converted into digital images. These studies are absorbe por todas las células en el cuerpo y es atrapado por las cé - more reliable in differentiating malignant cells from normal cells. lulas tumorales que emiten rayos gamma que son a su vez captados por la gamma cámara y convertidos en imágenes digitales. Estos estudios son más confiables al diferenciar células malignas de cé - lulas normales. key words: breast, molecular, PET. Palabras claves: mama, molecular, PET. Introduction rate for patients. Xeromammography, analog mammography, digi - Anatomy images are the basis for the detection of tal mammography and ultrasound detect cancer breast cancer since the implementation of the mam - characterizing the morphological appearance of tu - mography in the 70s and ultrasound in the 80s. mors. This requires for analysis patterns on the ap - Prior to that, breast cancer could only be detected pearance of the tumor, whether it is a mass, an when it was clinically evident, as a palpable mass. architectural distortion or a calcification. At that time, breast imaging was opening new When cancer is visible in mammography or ul - doors, which made the detection of breast tumors trasound the tumor growth has already exceeded possible since they were identified in a two-dimen - one trillion of cells in a process, which lasts more sional plane and, thus, there was a better survival than 10 years. Datos de contacto: María Victoria Velásquez, M.D. Lynn Cancer Institute. Boca Raton Regional Hospital. Recibido: de diciembre de / Aceptado: de febrero de Meadows Road Boca Raton, Florida - U.S.A Recieved: December th / Accepted: February st e-mail: [email protected] Vol. / Nº - Abril, . Molecular imaging in the evaluation of the breast Velázquez, M. V. More recently, the use of Magnetic Resonance vessels to form, that moment is when more cell re - (MR) has increased in the evaluation of the breast. plication takes place. Our goal as breast radiolo - This functional imaging method detects breast tu - gists must be the detection of cancer before mors due to their neovascularization. When tumors neovascularization starts. develop, there is initially a diffusion of nutrients and oxygen from the interstitial tissue. In a given time, cells become hypoxic since that diffusion is insuf - Types of molecular breast imaging ficient to maintain the growth. That is when che - motactic agents are released as Vascular Endothelial Molecular breast studies are becoming very useful Growth Factor (VEGF), which can cause the forma - alternatives for the evaluation of the primary and tion of new abnormal blood vessels around the metastatic tumor disease. tumor. These vessels have a discontinuous base - Breast-Specific Gamma Imaging (BSGI), Molecular ment membrane causing an escape from fluids Breast Imaging (MBI), Positron Emission Tomo - around the tumor. graphy (PET) and Positron Emission Mammography The dynamic study with a contrast agent in MR (PEM) constitute the repertoire of studies, which re - evaluates the process of neovascularization to arrive veal the metabolic activity of the tumor through a at the diagnosis of cancer. When looking at the radiopharmaceutical uptake. three-dimensional signal before and after the con - The isotope is absorbed by the cells in the body trast injection, the change in the time of that enhan - and trapped by tumor cells emitting gamma rays, cement is evaluated and this permits an estimate of which at the same time, are detected by the gamma the probability of malignancy. This is how a two- camera and turned into digital imaging. These stu - dimensional level becomes four-dimensional since dies are more reliable since they differentiate ma - a fourth dimension is added to the three-dimensio - lign from normal cells. nal image, i.e., time. The goal for the 21st century is to identify breast cancer before they are palpable or evident with the Scintimammography conventional anatomy detection tools. Molecular breast imaging is available since 1990 This is a nuclear study used to evaluate tumor cells through the evaluation with the Positron Emission based on their metabolism. The use of Technetium Tomography (whole body PET). This technique is 99 (Tc99) Sestamibi for the detection of breast can - excellent for the identification of metastatic lesions cer was reported in 1992 during its evaluation as a related to breast cancer; however, it is limited for cardiac agent. Since then multiple techniques have the identification and location of small tumors in been evaluated using planar computed tomography the mammary gland. Any type of study, which de - with single photon radioisotope emission and con - tects the metabolic activity of the individual cells, ventional gamma cameras for the detection of bre - has the potential of making the distinction between ast cancer (1). Tailefer reported in a meta-analysis normal and abnormal cells. This is the essential with 5,660 patients a sensitivity of 84% and a spe - process of the images with PET. cificity of 86% (2). However, in tumors with a size Cancer is known to have an uncontrolled cell re - of less than 15 mm, the sensitivity was as low as plication developing an increased metabolism of 50%. the glucose. Its distribution among normal and ab - Conventional gamma cameras are not widely normal cells is evaluated through a radioactive glu - used in breast imaging due to the 18% of resolution cose injection (F18 FDG). energy and the excessive distance between the Understanding the identification mechanism of organ and the detector, which does not permit the tumor cells with PET and MR, it seems like PET has detection of small tumors. In order to make up for the ability to detect cancer in an earlier stage than this and taking into account the potential that the MR does. The increase in the production of energy scintimammography offers in breast evaluation, in the cell occurs before there is incitement for new specific cameras have been developed for the eva - Revista Argentina de Diagnóstico por Imágenes Molecular imaging in the evaluation of the breast Velázquez, M. V. luation of the gland. Bsgi: breast-specific gamma imaging The new cameras have a resolution of 3 mm and they obtain images similar to the mammography. As mentioned before, photons emission is detected The distance between the camera and the object by the new special camera for the breast. These was reduced with this new configuration, only vi - cameras have a head of compact detectors in a sualizing the breast. This new cameras permitted space of 6 x 8 x 4 inches. Each detector has 3000 and increase of 85% in the sensitivity of the study crystals of Sodium Iodide and 48 multiplying tubes, in lesions smaller than 1 cm (3). which are sensitive to the position. The detectors are easy to handle and they have direct contact with the breast and the thoracic wall, minimizing the Grounds for breast imaging with dead space (Figure 1). technetium 99m Sestamibi This configuration with a head of detectors and a compression plate allows for the detection of le - Scintimammography purely offers physiological sions as small as 3 millimeters and they resemble information due to the cell uptake of the radioactive standard mammography projections. The camera tracer (Sestamibi), which is retained in the tumor is small and portable eliminating modifications in cells due to its abnormal metabolism. The emitted installation and workspace (6). radiation in photons from these cells is detected with a specific gamma camera converting that sig - nal into functional images or hot spots (4). The iso - tope used is Technetium 99 Sestamibi, a lipophilic agent, which accumulates in the mitochondrion. The 99 Tc lasts for 6 hours and produces 140 KeV photons. The affinity of the breast tumor cells though the ra - diopharmaceutical has two mechanisms: 1 - The agent is distributed regularly through the circulatory system but it accumulates in malign tu - Fig. : Detection of photons, which are emit - mors due to their neovascularization.
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