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Prone Versus Supine Breast FDG-PET/CT for Assessing Locoregional Disease Distribution in Locally Advanced Breast Cancer

Posted Jun 30, 2015 Updated Apr 10, 2023
By Richard G. Abramson MD , Katrina F. Lambert MD , Laurie B. Jones-Jackson MD , Lori R. Arlinghaus PhD , Jason Williams PhD , Vana G. Abramson MD , A. Bapsi Chakravarthy MD , Thomas E. Yankeelov PhD
11 min read

Rationale and Objectives

Prone 18 F fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) may have advantages for breast imaging because of improved separation of deep anatomic structures. There are limited data on whether prone and supine FDG-PET/CT provide similar information regarding breast and axillary disease in the setting of locally advanced breast cancer (LABC). The purpose of this study was to compare the information on locoregional disease distribution provided by prone versus supine FDG-PET in newly diagnosed LABC.

Materials and Methods

In an Institutional Review Board-approved prospective trial, 24 patients with newly diagnosed LABC underwent both supine and prone FDG-PET/CT at the same scanning session. Three readers performed an independent review of all scans and categorized the locoregional disease distribution as breast only (BO)-unifocal, BO-multifocal, BO-multicentric, or breast + axillary involvement. For breast + axillary disease, the readers also assessed the number of involved axillary lymph nodes. Interobserver discrepancies were resolved at a consensus reading session.

Results

Two scanning sessions were excluded because the prone scan had omitted part of the axilla from the field of view. In the remaining 22 patients, the consensus categorization of anatomic disease distribution was concordant between prone and supine scanning in 21 patients (linear kappa 0.91, 95% confidence interval [0.79–1]). In the 16 patients with breast + axillary disease, equal numbers of involved lymph nodes were identified on prone and supine scanning in 12 patients, whereas in the remaining four patients, prone scanning resulted in a higher number of visualized lymph nodes.

Conclusions

Prone and supine FDG-PET/CT provided statistically identical information on locoregional disease distribution in LABC. However, prone scanning may perform better than supine for assessing the number of involved lymph nodes. Prone FDG-PET/CT may be useful in future clinical and research efforts, including hybrid PET–magnetic resonance imaging (MRI) applications.

Introduction

18 F fluorodeoxyglucose positron emission tomography (FDG-PET) is useful for the initial staging of locally advanced breast cancer (LABC) and for restaging breast cancer in the setting of recurrence . FDG-PET is typically performed with the patient in the supine position, but some initial studies have suggested that prone scanning may be more effective in breast cancer because of better separation of deep breast tissue, axillary, and chest wall structures . The recent introduction of hybrid PET–magnetic resonance imaging (MRI) scanners provides additional motivation for studying prone FDG-PET of the breast, as breast MRI is currently performed with the patient in the prone position, prone FDG-PET may achieve better anatomic correlation with prone breast MRI in hybrid imaging applications .

At present, there are limited data on whether prone FDG-PET provides the same information as supine FDG-PET on locoregional disease distribution in breast cancer. Although FDG-PET does not currently play a major role in the clinical assessment of tumor multifocality or axillary nodal staging, these are areas in which FDG-PET performance may improve and new FDG-PET indications may emerge, especially with the evolution of higher spatial resolution positron emission mammography and hybrid PET-MRI systems . We therefore undertook this study to compare the information offered by prone versus supine FDG-PET in the context of newly diagnosed LABC. We investigated differences between prone and supine scanning in (1) qualitative categorization of the anatomic distribution of disease and (2) assessment of the number of involved axillary lymph nodes.

Materials and methods

Patients

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FDG-PET Imaging

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Figure 1, Custom-built breast support device for acquiring prone PET-CT images. It allows the breasts to lie pendant during the scanning procedure, thus replicating anatomic positioning during prone breast MRI. CT, computed tomography; MRI, magnetic resonance imaging; PET, positron emission tomography.

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Data Extraction

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Statistical Analysis

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Results

Patient and Tumor Characteristics

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Table 1

Patient Demographic Information and Tumor Characteristics

Patient Age Diameter (Technique) Histologic Type Histologic Grade Proliferative Rate Receptor Overexpression ER PR HER2 A 48 4.2 cm (US) IMC-NST High High − − − B 46 NDM IMC-NST High Intermediate + + + C 39 10 cm (PE) ILC Low Low + + − D 56 n/a IMC-NST High Intermediate + − + E 54 9 cm (US) IMC-NST High n/a + − − F 64 2 cm (US) IMC-NST High n/a − − − G 32 2.9 cm (US) IMC-NST High High + + + H 49 1.3 cm (US) IMC-NST High Intermediate − − + I 67 2.4 cm (US) IMC-NST High High − − − J 39 1.9 cm (MRI) IMC-NST High Intermediate − − − K 33 4.3 cm (MRI) IMC-NST High High + + — L 44 8 cm (PE) IMC-NST High n/a − − − M 57 3 cm (US) IMC-NST High High − − − N 43 1.8 cm (US) IMC-NST High High − − − O 42 1.8 cm (US) IMC-NST High High − − − P 48 NDM IMC-NST High n/a − − + Q 45 3 cm (US) IMC-NST High High − + − R 50 2 cm (MRI) IMC-NST Intermediate Intermediate − − − S 55 3 cm (US) IMC-NST Intermediate Intermediate + + − T 43 2.9 cm (MRI) IMC-NST High High − − − U 36 1.6 cm IMC-NST Intermediate Low + + − V 65 4.6 cm IMC-NST Intermediate Intermediate − − + W 42 3.6 cm IMC-NST Intermediate Intermediate + + − X 56 n/a IMC-NST High High + + −

ER, estrogen receptor; HER2, human epidermal growth factor receptor type 2; ILC, invasive lobular carcinoma; IMC-NST, invasive mammary carcinoma, no special type; MRI, magnetic resonance imaging; NDM, no discrete mass; n/a, not available; PE, physical examination; PR, progesterone receptor; US, ultrasound.

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Acquisition Times

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Table 2

Scan Acquisition Times

Patient Start Times (Minutes After Fluorodeoxyglucose Injection) Prone-Supine Delay (min) Prone Supine A 64.48 77.25 12.77 B 61.05 72.78 11.73 C 64.8 76.28 11.48 D 70.38 85.73 15.35 E 58.05 79.23 21.18 F 61.15 73.17 12.02 G 71.02 81.23 10.21 H 60.23 71.75 11.52 I 61.88 71.62 9.74 J 64.27 75.32 11.05 K 62.48 73.00 10.52 L 64.5 74.95 10.45 M 62.48 73.00 10.52 N 54.5 65.98 11.48 O 55.32 65.82 10.50 P 59.98 69.83 9.85 Q 60.05 71.52 11.47 R 62.42 73.37 10.95 S 60.00 69.68 9.68 T 60.05 71.45 11.40 U 60.00 70.20 10.20 V 62.48 76.43 13.95 W 78.20 92.35 14.15 X 68.70 79.35 10.65

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Scan Quality

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Figure 2, A 48-year-old patient (patient P) with a high-grade invasive mammary carcinoma of the right breast. Frontal three-dimensional maximum intensity projection reconstructions from 18 F-FDG–PET imaging acquired in the (a) prone and (b) supine positions. Two right axillary lymph nodes seen on the supine scan ( arrow ) were excluded from the field of view on the prone scan. FDG, fluorodeoxyglucose; PET, positron emission tomography.

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Categorization of Anatomic Disease Distribution

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Table 3

Comparison of Prone and Supine Scanning for Categorization of Anatomic Disease Distribution

Patient Prone Supine Result Comments A Breast + axilla Breast + axilla Concordant B Breast + axilla Breast + axilla Concordant C BO-multifocal BO-unifocal Discordant Low-grade invasive lobular carcinoma, very low metabolic activity D Breast + axilla Breast + axilla Concordant E Breast + axilla Breast + axilla Concordant F Breast + axilla Breast + axilla Concordant G Breast + axilla Breast + axilla Concordant H Breast + axilla Breast + axilla Concordant I — — — Excluded because of part of axilla omitted from the field of view on prone scan J BO-unifocal BO-unifocal Concordant K Breast + axilla Breast + axilla Concordant L Breast + axilla Breast + axilla Concordant M Breast + axilla Breast + axilla Concordant N Breast + axilla Breast + axilla Concordant O BO-unifocal BO-unifocal Concordant P — — — Excluded because of part of axilla omitted from the field of view on prone scan Q BO-unifocal BO-unifocal Concordant R BO-unifocal BO-unifocal Concordant S BO-unifocal (bilateral) BO-unifocal (bilateral) Concordant T Breast + axilla Breast + axilla Concordant U Breast + axilla Breast + axilla Concordant V Breast + axilla Breast + axilla Concordant W Breast + axilla Breast + axilla Concordant X Breast + axilla Breast + axilla Concordant

BO, breast only.

Figure 3, A 39-year-old patient (patient C) with a 10 cm low-grade invasive lobular carcinoma of the right breast. 18 F-FDG–PET imaging acquired in the (a) prone and (b) supine positions. This tumor exhibited very low metabolic activity and was discordantly categorized as having multifocal distribution on prone scanning but unifocal distribution on supine. FDG, fluorodeoxyglucose; PET, positron emission tomography.

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Assessment of Number of Involved Lymph Nodes

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Table 4

Comparison of Prone and Supine Scanning for Quantification of Involved Lymph Nodes

Patient Prone Supine Result Comments A 3 3 Concordant B 6 5 Discordant Better anatomic separation of deep structures on prone scan C — — D 1 1 Concordant E 7 4 Discordant Better anatomic separation of deep structures on prone scan F 4 3 Discordant Better anatomic separation of deep structures on prone scan G 2 2 Concordant H 1 1 Concordant I 7 8 — Excluded because of part of axilla omitted from the field of view on prone scan J — — K 2 2 Concordant L 2 2 Concordant M 2 2 Concordant N 1 1 Concordant O — — P 0 3 — Excluded because of part of axilla omitted from the field of view on prone scan Q — — R — — S — — T 1 1 Concordant U 9 5 Discordant Better anatomic separation of deep structures on prone scan V 3 3 Concordant W 4 4 Concordant X 2 2 Concordant

Figure 4, A 46-year-old patient (patient B) with a high-grade invasive mammary carcinoma of the left breast. Oblique three-dimensional maximum intensity projection reconstructions from 18 F-FDG–PET imaging acquired in the (a) prone and (b) supine positions. Four discrete hypermetabolic left axillary lymph nodes can be resolved on the prone scan but only three are visible on the supine scan ( arrows ). Two hypermetabolic supraclavicular lymph nodes are also noted ( arrowheads ). FDG, fluorodeoxyglucose; PET, positron emission tomography.

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Discussion

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Conclusions

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Acknowledgments

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Academic Radiology, Volume 22, Issue 7
Journals General Radiology
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