Home Breast-specific Gamma Imaging in the Detection of Atypical Ductal Hyperplasia and Lobular Neoplasia
Post
Cancel

Breast-specific Gamma Imaging in the Detection of Atypical Ductal Hyperplasia and Lobular Neoplasia

Posted May 31, 2012 Updated Apr 10, 2023
By Caroline M. Ling MD , Caitrín M. Coffey BS , Jocelyn A. Rapelyea MD , Jessica Torrente MD , Christine B. Teal MD , Anita P. McSwain MD , Rachel F. Brem MD
11 min read

Rationale and Objectives

Atypical lesions such as atypical ductal hyperplasia (ADH) and lobular neoplasia are nonmalignant lesions that are associated with significant increased risk of developing breast cancer. Atypical lesions have been reported to present with focal increased radiotracer uptake on breast-specific gamma imaging (BSGI) examination, a novel physiologic tool for the detection of breast cancer. To date the sensitivity of BSGI in the detection of atypical lesions has not been reported. The purpose of this study is to determine the sensitivity of BSGI in detecting ADH and lobular neoplasia.

Materials and Methods

A total of 1316 patients who received a BSGI exam between January 2006 and July 2009 were retrospectively reviewed. All patients who underwent minimally invasive biopsy and subsequent surgical excision where the highest pathology was solely ADH or lobular neoplasia (reported as ALH, lobular carcinoma in situ or lobular neoplasia), according to the pathology database were included ( n = 15). The sensitivity was determined as the percentage of positive BSGI exams out of all patients diagnosed with ADH or lobular neoplasia who received a BSGI.

Results

Patient ages ranged from 39 to 67 (mean, 52). Eight of 15 patients had ADH, 6/15 lobular neoplasia, and 1/15 ADH and lobular neoplasia in one lesion. Fifteen of the 15 (100%) patients with surgically confirmed ADH or lobular neoplasia had a positive BSGI, with focally increased radiotracer uptake at the site of the verified high-risk lesion.

Conclusion

BSGI has a high sensitivity for the detection of atypical, high-risk breast lesions. A diagnosis of an atypical lesion is concordant with focal increased radiotracer uptake with BSGI and can identify women at increased risk for breast cancer.

Breast-specific gamma imaging (BSGI) is an adjunct technology used to complement mammography and ultrasound in the detection and follow-up of breast cancer. There has been a recent resurgence of gamma imaging since the advent of high-resolution, small field of view gamma cameras. Nuclear imaging identifies areas of the breast that have increased metabolism as compared with normal breast tissue, complementing mammography by detecting cancer physiologically rather than anatomically. BSGI has a sensitivity of 96.4% for detecting carcinoma, 91% for ductal carcinoma in situ (DCIS), and 93% for invasive lobular carcinoma (ILC) . The sensitivity of BSGI is comparable to that of magnetic resonance imaging (MRI), but BSGI has shown to have a higher specificity for carcinoma . BSGI is already being used clinically at many centers. Clinical and research indications suggested by the Society of Nuclear Imaging include: evaluation of patients with recently diagnosed malignancy, patients at high risk of breast malignancy, patients with indeterminate breast abnormalities with remaining diagnostic concern, patients with technically difficult breast imaging, patients in whom MRI is contraindicated, and to monitor patients’ responses to preoperative neoadjuvant chemotherapy . Recently, the American College of Radiology began an accreditation program for BSGI, further demonstrating its increasing inclusion in the armamentarium of tools for the improved diagnosis of breast cancer .

A BSGI study shows increased radiotracer uptake in areas of increased metabolism in the breast (ie, cancers as well as nonmalignant lesions such as inflammatory processes, fibroadenomas, papillomas, and atypical lesions) . Reports of BSGI’s specificity for breast cancer range from 59.5% to 93% . High-risk lesions such as atypical ductal hyperplasia (ADH) and lobular neoplasias have been reported to demonstrate increased radiotracer uptake in BSGI examination in recent studies; however, most current studies have considered high-risk lesions to be false positives with the focus of the study being carcinoma or DCIS .

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Materials and methods

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Results

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Table 1

Sensitivity of BSGI for Atypical Lesions Based on Reason for BSGI Examination

Reason for BSGI Number of Patients BSGI Sensitivity for Atypical Lesion Equivocal or suspicious mammographic or ultrasound findings 7 7/7 (100%) Evaluation for occult lesions after new breast cancer diagnosis 7 7/7 (100%) High-risk surveillance 1 1/1 (100%)

BSGI, breast-specific gamma imaging.

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Figure 1, (a) A 55-year-old female with biopsy-proven ductal carcinoma in situ (DCIS) in the right breast underwent bilateral breast-specific gamma imaging (BSGI) in the craniocaudal (CC) and mediolateral oblique (MLO) views to assess extent of disease and detect occult disease. BSGI revealed 2-cm area of focally increased radiotracer uptake in the right breast corresponding to biopsy-proven DCIS as well as foci of increased radiotracer uptake in the medial superior right (A) and lateral left (B) breast with no corresponding abnormality on mammography. (b) Second-look ultrasound demonstrated hypoechoic lesions in the right 2 o'clock (A) and left 3 o'clock (B) positions corresponding to the areas of increased radiotracer uptake. Ultrasound-guided core needle biopsy revealed a papillary lesion with atypia in the right breast (A) as well as atypical ductal hyperplasia in the left breast (B). Patient subsequently opted for a double mastectomy and final pathology showed right DCIS with small foci of invasive ductal carcinoma (IDC) at the site of known cancer, right papillary lesion with atypia (A), and left ADH (B).

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Figure 2, A 62-year-old female with a history of lobular carcinoma in situ and family history of breast cancer. (a) Breast-specific gamma imaging (BSGI) showed focally increased radiotracer uptake in the superior right breast on the mediolateral view ( arrow ). Second-look ultrasound was unremarkable; therefore, magnetic resonance imaging was used to target the lesion for biopsy. (b) T1 fat-suppressed post-dynamic contrast-enhanced image demonstrates focal area of enhancement in the superior right breast corresponding to focus of radiotracer uptake on BSGI ( arrow ). This area was targeted with magnetic resonance-guided biopsy which revealed a sclerosing papilloma with atypical lobular hyperplasia. Subsequent surgical excision showed extensive lobular neoplasia.

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Table 2

Sensitivity of BSGI for Atypical Lesions Based on Pathology

Pathology Number of Patients BSGI Sensitivity for Atypical Lesion atypical ductal hyperplasia 8/15 8/8 (100%) lobular neoplasia 6/15 6/6 (100%) Atypical ductal hyperplasia and lobular neoplasia (mixed lesion) 1/15 1/1 (100%)

BSGI, breast-specific gamma imaging.

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Discussion

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

Get Radiology Tree app to read full this article<

References

  • 1. Brem R.F., Petrovitch I., Rapelyea J.A., et. al.: Breast-specific gamma imaging with 99mTc-Sestamibi and magnetic resonance imaging in the diagnosis of breast cancer—a comparative study. Breast 2007; 13: pp. 465-469.

  • 2. Brem R.F., Floerke A.C., Rapelyea J.A., et. al.: Breast-specific gamma imaging as an adjunct imaging modality for the diagnosis of breast cancer. Radiology 2008; 247: pp. 651-657.

  • 3. Brem R.F., Fishman M., Rapelyea J.A.: Detection of ductal carcinoma in situ with mammography, breast specific gamma imaging, and magnetic resonance imaging: a comparative study. Acad Radiol 2007; 14: pp. 945-950.

  • 4. Brem R.F., Ioffe M., Rapelyea J.A., et. al.: Invasive lobular carcinoma: detection with mammography, sonography, MRI, and breast-specific gamma imaging. Am J Roentgenol AJR 2009; 192: pp. 379-383.

  • 5. Goldsmith S.J., Parsons W., Guiberteau M.J., et. al.: The SNM procedure guideline for breast scintigraphy with breast specific γ-cameras 1.0. J Nucl Med Technol 2010; 38: pp. 219-224.

  • 6. American College of Radiology. Diagnostic modality accreditation program: nuclear medicine/PET accreditation program requirements. http://www.acr.org/accreditation/nuclear/nuc_med_reqs.aspx . Revised June 27, 2011; accessed August 4, 2011.

  • 7. Brem R.F., Rapelyea J.A., Zisman G., et. al.: Occult breast cancer: scintimammography with high-resolution breast-specific gamma camera in women at high risk for breast cancer. Radiology 2005; 237: pp. 274-280.

  • 8. Rhodes D.J., Hruska C.B., Phillips S.W., et. al.: Dedicated dual-head gamma imaging for breast cancer screening in women with mammographically dense breasts. Radiology 2011; 258: pp. 106-118.

  • 9. Brem R.F., Shahan C., Rapelyea J.A., et. al.: Detection of occult foci of breast cancer using breast-specific gamma imaging in women with one mammographic or clinically suspicious breast lesion. Acad Radiol 2010; 17: pp. 734-743.

  • 10. Boecker W., Buerger H., Herbst H., et. al.: Atypical ductal hyperplasia.Boecker W.Preneoplasia of the breast.2006.ElsevierMunich:pp. 379-406.

  • 11. Tavasolli F.A.: Lobular and ductal intraepithelial neoplasia. Pathologe 2008; 29: pp. 107-111.

  • 12. Jackman R.J., Birdwell R.L., Ikeda D.M.: Atypical ductal hyperplasia: can some lesions be defined as probably benign after stereotactic 11-gauge vacuum-assisted biopsy, eliminating the recommendation for surgical excision?. Radiology 2002; 224: pp. 548-554.

  • 13. Darling M.L., Smith D.N., Lester S.C., et. al.: Atypical ductal hyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision. Am J Roentgenol AJR 2000; 175: pp. 1341-1346.

  • 14. Brem R.F., Sanow L., Behrndt V.S., et. al.: Reliability of atypical ductal hyperplasia: histologic underestimation of carcinoma in tissue harvested from impalpable breast lesions using 11-gauge stereotactically guided directional vacuum-assisted biopsy. Am J Roentgenol AJR 1999; 172: pp. 1405-1407.

  • 15. Page D.L., Dupont W.D., Rogers L.W., et. al.: Atypical hyperplastic lesions of the female breast: a long term follow up study. Cancer 1985; 55: pp. 2689-2708.

  • 16. Rampaul R.S., Pinder S.E., Robertson J.F., et. al.: Lobular neoplasia.Boecker W.Preneoplasia of the breast.2006.ElsevierMunich:pp. 467-484.

  • 17. Page D.L., Kidd T.E., Dupont W.D., et. al.: Lobular neoplasia of the breast: higher risk for subsequent invasive cancer predicted by more extensive disease. Hum Pathol 1991; 22: pp. 1232-1239.

  • 18. Chuba P.J., Hamre M.R., Yap J., et. al.: Bilateral risk for subsequent breast cancer after lobular carcinoma-in-situ: analysis of surveillance, epidemiology, and end results data. J Clin Oncol 2005; 23: pp. 5534-5541.

  • 19. Page D.L., Schuyler P.A., Dupont W.D., et. al.: Atypical lobular hyperplasia as a unilateral predictor of breast cancer risk: a retrospective cohort study. Lancet 2003; 361: pp. 125-129.

  • 20. Nayar R., Zhuang Z., Merino M.J., et. al.: Loss of heterozygosity on chromosome 11q13 in lobular lesions of the breast using microdissection and polymerase chain reaction. Hum Pathol 1997; 28: pp. 277-282.

  • 21. Green A.R., Krivinskas S., Young P., et. al.: Loss of expression of chromosome 16q genes DPEP1 and TCF in lobular carcinoma in situ of the breast. Breast Cancer Res Treat 2009; 113: pp. 59-66.

  • 22. Brem R.F., Lechner M.C., Jackman R.J., et. al.: Lobular neoplasia at percutaneous breast biopsy: variables associated with carcinoma at surgical excision. Am J Roentgenol AJR 2008; 190: pp. 637-641.

  • 23. Liberman L.: Clinical management issues in percutaneous core breast biopsy. Radiol Clin N Am 2000; 4: pp. 791-807.

  • 24. Liberman L., Sama M., Susnik B., et. al.: Lobular carcinoma in situ at percutaneous breast biopsy: surgical biopsy findings. Am J Roentgenol AJR 1999; 173: pp. 291-299.

  • 25. Sohn V.Y., Arthurs Z.M., Kim F.S., et. al.: Lobular neoplasia: is surgical excision warranted?. Am Surgeon 2008; 74: pp. 172-177.

  • 26. Page D.L., Simpson J.F.: What is atypical lobular hyperplasia and what does it mean for the patient?. J Clin Oncol 2005; 23: pp. 5432-5433.

  • 27. King M., Wiend S., Hale K., et. al.: Tamoxifen and breast cancer incidence among women with inherited mutations in BRCA1 and BRCA2: National Surgical Adjuvant Breast and Bowel Project (NSABP-P1) Breast Cancer Prevention Trial. JAMA 2001; 286: pp. 2251-2256.

  • 28. An act requiring the communication of mammographic breast density information to patients. Public Act No. 09-41, Connecticut, 2009. http://www.cga.ct.gov/2009/ACT/PA/2009PA-00041-R00SB-00458-PA.htm . Accessed August 4, 2011.

  • 29. An act concerning regulation; article V: improving state healthcare programs with respect to mammography and breast cancer treatment. Illinois, 2009. http://www.ilga.gov/legislation/publicacts/fulltext.asp?Name=095–1045 . Accessed August 4, 2011.

  • 30. Delmon-Moingeon L.I., Piwnica-Worms D., Van den Abbeele A.D., et. al.: Uptake of the cation hexakis(2-methoxyisobutylisonitrile)-technetium-99m by human carcinoma cell lines in vitro. Cancer Res 1990; 50: pp. 2198-2202.

  • 31. Sharma S., Sharma M.C., Sarkar C.: Morphology of angiogenesis in human cancer: a conceptual overview, histoprognostic perspective and significance of neoangiogenesis. Histopathology 2005; 46: pp. 481-489.

  • 32. Saslow D., Boetes C., Burke W., et. al.: American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography. CA: A Cancer J Clinicians 2007; 57: pp. 75-89.

  • 33. Port E.R., Park A., Borgen P.I., et. al.: Results of MRI screening for breast cancer in high-risk patients with LCIS and atypical hyperplasia. Ann Surg Oncol 2006; 14: pp. 1051-1057.

  • 34. Tchou J., Nanjiang H., Rademaker A., et. al.: Acceptance of tamoxifen chemoprevention by physicians and women at risk. Cancer 2004; 100: pp. 1800-1806.

  • 35. Lehman C.D., Gatsonis C., Kuhl C.K., et. al.: MRI Evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med 2007; 356: pp. 1295-1303.

  • 36. Zhou M., Johnson N., Gruner S., et. al.: Clinical utility of breast-specific gamma imaging for evaluating disease extent in the newly diagnosed breast cancer patient. Am J Surg 2009; 197: pp. 159-163.

  • 37. Hendrick R.E.: Radiation doses and cancer risks from breast imaging studies. Radiology 2010; 257: pp. 246-253.

  • 38. O’Connor M.K., Li H., Rhodes D.J., et. al.: Comparison of radiation exposure and associated radiation-induced cancer risks from mammography and molecular imaging of the breast. Med Phys 2010; 37: pp. 6187-6198.

  • 39. Wagenaar D.J., Hugg J.W., Moats R.A., et. al.: Low-dose molecular breast imaging in radiographically dense breasts. J Nucl Med 2011; 52: pp. 674.

  • 40. Bohm-Velez M., Kieper D., Williams M.B., et. al.: A clinical evaluation of breast tissue uptake of Tc99m-sestamibi as a function of injected dose. J Nucl Med 2011; 52: pp. 667.

  • 41. O’Connor M.K., Weinmann A.L., Tortorelli C.L., et. al.: Low-dose molecular breast imaging. J Nucl Med 2011; 52: pp. 670.

Academic Radiology, Volume 19, Issue 6
Journals General Radiology
This post is licensed under CC BY 4.0 by the author.
Recently Updated
Contents