SHORT COMMUNICATION
T-A HEUSNER, MD, 2L S FREUDENBERG, MD, 1H KUEHL, MD, 1E A M HAUTH, MD, 1P VEIT-HAIBACH, MD,
M FORSTING, MD, 2A BOCKISCH, MD, PhD and 1G ANTOCH, MD
Departments of 1Diagnostic and Interventional Radiology and Neuroradiology and 2Nuclear Medicine, University
Hospital Essen, Germany
ABSTRACT. The purpose of this study was to evaluate the feasibility and utility of a
dedicated positron emission tomography (PET)/CT protocol in breast cancer patients. 40
patients with suspected recurrent breast cancer underwent whole-body PET/CT in the
supine position (SP) followed by PET/CT of the breasts and axillae in the prone position
(PP) using a special positioning aid. PP and SP images were compared in terms of the
tumour-to-thoracic-wall distance, tumour-to-skin distance and tumour volume,
diameter, density, maximal standardized uptake value (SUVmax) and localization. The
size of axillary areas, the number of intra-axillary lymph nodes, their transverse
diameters, their SUVmax and the number of distant metastases were compared between
PP and SP images. Differences were tested for significance using the Students t-test. All
patients tolerated PP imaging well. Five locally recurrent breast cancers were detected,
both in the SP and in the PP. Mean tumour-to-thoracic-wall distances (PP, 19 mm; SP,
8 mm; p50.003) and tumour-to-skin distances (PP, 10 mm; SP, 7 mm; p50.013) were
significantly larger in the PP than in the SP. Potential thoracic wall or skin infiltration, as
well as quadrant localization, were determined more easily in PP. The axillary area was
wider in the PP when compared with SP (PP, 14.4 cm2; SP, 10.6 cm2; p,0.001). No other
parameters were significantly different. In conclusion, a dedicated whole-body PET/CT
examination, including PET/CT mammography, is feasible for clinical practice and may
offer important information on the possible infiltration of a breast lesion into the
adjacent thoracic wall and skin. Even though the axilla may be delineated more clearly
in the PP, there seems to be no benefit with regard to N-staging.
PET/CT system/workstation
PET/CT imaging was performed on a biograph2 PET/
CT system (Siemens Molecular Imaging, Hoffman Estates,
IL) composed of a dual-slice CT scanner (Somatom
Emotion2; Siemens Medical Solutions, Forchheim,
Germany) and a full-ring PET scanner (ECAT HR+2;
Siemens Molecular Imaging, Hoffman Estates, IL). The
PET system had an axial field of view of 15.5 cm per bed
position and an in-plane spatial resolution of 4.6 mm. CT
was performed first, followed by PET.
All measurements were performed on an AW Suite2
Workstation (General Electrics Healthcare, Munich,
Germany). Differences between measurements made in
the supine position (SP) and the prone position (PP) were
tested for significance (p,0.05) with the Students t-test.
One radiologist and one nuclear medicine physician with
more than 3 years of experience in PET/CT evaluated all
images in consensus.
Imaging protocol
The dedicated breast PET/CT protocol consisted of
two parts. Firstly, a whole-body PET/CT scan was
performed in the SP, covering a field of view from the
head to the upper thighs. Image acquisition was
performed in the caudocranial direction with 100 mAs
and 130 kV. 140 ml of an intravenous contrast agent
(Ultravist 3002; Schering AG, Berlin, Germany) containing 300 mg ml1 of iodine were administered with an
automated injector (XD 55002; Ulrich Medical Systems,
Ulm, Germany) with a flow rate of 3 ml s1 for the first
90 ml, and 1.5 ml s1 for the following 50 ml. The start
delay was 50 s. Images were reconstructed with a 5 mm
slice thickness and a 2.4 mm increment. Following
acquisition of the CT data, PET images were obtained
60 min after injection of ,340 MBq of 18F-fluorodeoxyglucose (FDG). PET emission time was adapted to the
patients body weight: ,65 kg, 4 min per bed position;
6585 kg, 5 min per bed position; and .85 kg, 6 min per
bed position. Iterative algorithms (FORE (Fourier rebinning) and AWOSEM (attenuation-weighted expectation
maximization), non-linear) with two iterations and eight
subsets were used for image reconstruction. Data were
filtered (FWHM (full width at half maximum) 5.0 mm)
and scatter was corrected.
The second part of the breast-specific protocol was
performed after repositioning the patient into the PP
using a special breast positioning aid (Additec Mamma
Comfort2; Additec GmbH, Markt Indersdorf, Germany;
Figure 1). A topogram in the lateral view was performed
to define the scan range from the axilla to the lower end of
the breasts. No additional contrast medium was applied
for PET/CT in the PP. Image acquisition was performed
in a caudocranial direction. CT parameters were the same
as those in the SP. The number of PET bed positions was
adapted to include the breasts and axillae. This resulted in
744
one or two bed positions for the prone scan. PET emission
time was set to either 6 min or 7 min, depending on the
volume of the breast. PET image reconstruction was
performed according to the SP protocol.
Technical feasibility
All patients were questioned for potential discomfort
during prone imaging compared with supine imaging.
The additional time (min) required for prone imaging
was reported, as was the number of additionally
required bed positions.
(a)
(b)
(c)
(d)
Figure 2. Contralateral breast cancer manifestation in a 47-year-old woman on (a,b) fluorodeoxyglucose positron emission
tomography (FDG-PET)/CT and on (c,d) CT; the tumour can be more clearly distinguished from adjacent structures in the prone
position (a,c) than in the supine position (b,d). On prone imaging, thoracic wall infiltration can be clearly negated because of
the fatty tissue separating the tumour and thoracic wall in the prone position (c) but not in the supine position (d).
Results
Delineation of breast lesions
Technical feasibility
All patients tolerated PET/CT in the PP well. The
additional time required for PP PET/CT was 205 min.
The British Journal of Radiology, September 2008
(a)
(b)
Figure 3. Visualization of axillary fat in (a) the prone position and (b) the supine position on CT. The axillary area measures
40 cm2 in the prone position and 24 cm2 in the supine position. Prone positioning offers a more extensive evaluation of the
axillary fat and its lymph nodes. 1, major pectoral muscle; 2, minor pectoral muscle; 3, latissimus dorsi muscle; 4, major teres
muscle.
1
2
3
4
5
21613
63635
12568
49626
19616
30613
64633
11965
51626
19616
746
Bone
Lymph nodes
Lung
Pleura
Liver
15
12
10
2
1
4
3
2
2
2
All lymph nodes listed are distant lymph node metastases, e.g. hilar or infracarinal lymph node metastases. 4 of 15 bone
metastases (26.7%) were not detected with CT alone, as were 3 of 12 lymph node metastases (25%).
PET, positron emission tomography.
Discussion
Initial results indicate that prone breast positioning
may improve the assessment of any potential infiltration
of breast tumour into the thoracic wall or the skin on
PET/CT. In addition, the axilla may be assessed more
easily for potential metastatic spread because of
enhanced anatomical visualization. Therefore, breast
imaging in the PP may be a helpful adjunct to wholebody PET/CT staging. Further studies are required to
assess the accuracy of whole-body PET/CT mammography for TNM (tumour, node, metastases) breast cancer
staging.
Different quadrants of the breast can be distinguished
more easily in the PP, with the potential to more
accurately localize a breast tumour. In particular, the
axillary tail of the breast seemed to be visualized more
thoroughly in the PP. This may be of particular interest
because the axillary tail of the breast harbours 48% of all
breast cancer manifestations [9]. This advantage of PP
compared with SP has been demonstrated for MR
mammography, where prone imaging is the method of
choice for visualization of the breast [10]. To improve
PET accuracy when assessing the breast for potential
lesions, breast positioning similar to that of MRI has been
proposed for PET imaging [11]. A substantial advantage
of the PP is the potential to better differentiate the
tumour from its adjacent structures. In the PP, fatty
tissue, as well as glandular tissue of the breast, is
uncompressed, thus offering clearer visualization of the
fatty lamella that separates the tumour from the thoracic
wall or the skin. In cases of thoracic wall or skin
infiltration, this fatty lamella will disappear, indicating
tumour invasion. Infiltration of the pectoral muscles or
the skin owing to a T4 carcinoma of the breast has
implications for patient management [12]. Thus, the early
detection of such locally advanced disease must be
considered of interest even before it has been detected by
pathology.
MR mammography has been found to have a higher
sensitivity for detecting malignant breast lesions than
FDG-PET [13]. Indeed, FDG-PET is at a disadvantage
when detecting malignant breast tumour lesions ,1 cm
because of its limited spatial resolution and the low
glucose uptake of well-differentiated tumours [2].
However, compared with other functional imaging
modalities, FDG-PET is still considered the most sensitive functional method for the detection of primary
breast carcinoma [2]. A sensitivity of 88% for the
detection of malignant breast lesions has been documented [14]. Anatomical correlation for FDG-PET, as
The British Journal of Radiology, September 2008
Conclusions
Whole-body PET/CT mammography is technically
feasible in clinical practice. If whole-body PET/CT is
indicated for tumour staging in patients with suspected
747
Acknowledgments
We thank Thomas Beyer, PhD, for his organizational
support and Additec GmbH for providing the positioning aid.
References
1. Agnese DM. Advances in breast imaging. Surg Technol Int
2005;14:516.
2. Scheidhauer K, Walter C, Seemann MD. FDG PET and other
imaging modalities in the primary diagnosis of suspicious
breast lesions. Eur J Nucl Med Mol Imaging 2004;31:709.
3. Buscombe JR, Holloway B, Roche N, Bombardieri E.
Position of nuclear medicine modalities in the diagnostic
work-up of breast cancer. Q J Nucl Med Mol Imaging
2004;48:10918.
4. Rausch DR, Hendrick RE. How to optimize clinical breast
MR imaging practices and techniques on your 1.5-T system.
Radiographics 2006;26:146984.
5. Antoch G, Vogt FM, Freudenberg LS, Nazaradeh F, Goehde
SC, Barkhausen J, et al. Whole-body dual-modality PET/CT
and whole-body MRI for tumor staging in oncology. JAMA
2003;24;290:3199206.
748