Clinical experience with 99mTc-MIBI scintimammography in patients with breast microcalcifications

The aim of this study was to evaluate whether 99mTc-MIBI scintimammography can improve the diagnostic value of mammography for the differentiation of benign and malignant breast microcalcifications. In 41 women presenting 45 clusters of microcalcifications, a 99mTc-MIBI scintimammography was performed before open biopsy. There were 24 malignant lesions (53%). The sensitivity (SE) and specificity (SP) of 99mTc-MIBI scintimammography were 58.3% and 81%, and the positive and negative predictive values (PPV, NPV) were 78% and 63%, respectively. SE and PPV increased for lesions over 10 mm and for the younger patients (under 50 years). No correlation was found between true positive uptake and breast cancer invasiveness: 69% (9/13) for invasive lesions and 45% (5/11) for noninvasive lesions (P = 0.48). 99mTc-MIBI scintimammography was more often positive in high grade than in low- or intermediate-grade ductal carcinoma in situ (P = 0.03). The results were analysed according to the morphologic aspect of the microcalcifications. 99mTc-MIBI scintimammography could not be used for routine evaluation of all the microcalcifications detected by mammography.     

99mTc-MIBI scintimammography as a complement of the mammography in patients with suspected breast cancer. A multicentre experience

The aim of this work has been to evaluate the clinical usefulness of 99mTc-MIBI scintimammography, used as a complement to mammography, in the study of patients with suspected breast cancer. We performed prone breast scintigraphy in 253 patients (268 lesions) with suspected breast cancer. The size and degree of the suspected breast cancer was evaluated by mammography. Diagnosis was established by biopsy. Malignancy was diagnosed in 155 lesions and benign diseases in 113. The results of the scintimammography were a sensitivity of 91%, a specificity of 71%, PPV=81% and NPV=85%. In lesions smaller than 1 cm, sensitivity and specificity were 57% and 100%; in lesions with a diameter of between 1 and 2 cm, these figures were 90% and 72% respectively, and in lesions of more than 2 cm the sensitivity was 99% and the specificity 50%. On mammography, 155 lesions were considered as having a high suspicion of malignancy, whilst 72 were indeterminate and 41 had a low probability. In lesions with a low or indeterminate suspicion of malignancy on mammography, the sensitivity and NPV of the scintimammography were 97% and 98%. Scintimammography is a useful technique in the study of lesions where breast cancer is suspected. Scintimammography results are closely related to tumour size and the degree of mammographic suspicion. Scintimammography can be useful where mammography identifies lesions with a low or indeterminate suspicion of malignancy.     

99mTc-MIBI乳腺显像与乳腺X线照相在乳腺癌诊断中的价值

目的评价^99m Tc-MIBI乳腺显像与乳腺X线照相检测乳腺癌的实用性。方法对100例106个经临床检查可疑乳腺病灶的妇女进行乳腺钼靶X线照相和^99m Tc-MIBI乳腺显像检查,并与病理学诊断结果进行对比。结果与病理组织学诊断比较,钼靶照相检测乳腺癌特异性为44．6％,阳性预测值为31．7％;^99m Tc-MIBI显像检测乳腺癌的特异性为87．8％,阳性预测值为76．9％。结论^99m Tc--MIBI乳腺显像对乳腺癌的诊断较乳腺X线照相具有较大的临床价值。     

Technetium-99m sestamibi scintimammography complements mammography in the detection of breast cancer

Mammography remains the technique of choice for the detection of early breast cancer. The sensitivity of mammography is 85%, but is decreased in patients with dense breasts. Sestamibi scintimammography (SCM) has been suggested as an adjunctive modality to improve the detection of breast cancer. We conducted a study to determine the impact of SCM in patient management. A prospective study was conducted in 95 patients presenting with palpable masses and/or abnormal mammography scheduled for biopsy. Injection of 20-30 mCi of technetium-99m (Tc-99m) sestamibi into a pedal vein was performed. Ten-minute images of the breast and axilla were obtained in multiple projections. The mammography and SCM were correlated with pathology and clinical findings. The median age was 44 years (range 28-86 years). The total number of lesions was 104, as eight patients had bilateral lesions and one patient had two lesions in the same breast. Fifty-nine patients presented with palpable lesions and 45 patients with nonpalpable lesions (42 with abnormal mammography only and 3 with nipple discharge). A comparison of sensitivity, specificity, positive and negative predictive values, and overall accuracy of SCM and mammography were performed. The sensitivity and specificity for SCM were 83% and 83%, respectively, and for mammography were 65%, and 72%, respectively. The sensitivity and specificity for combined SCM and mammography were 87% and 94%, respectively. The p-value for mammography versus combined SCM and mammography was 0.0003 and that for SCM versus SCM and mammography was 0.0098. There were 80 (77%) benign and 24 (23%) malignant lesions. Of the 24 malignancies, SCM missed six (25%), versus eight (33%) by mammography. In two patients (9%) SCM detected malignancy in the breast that was not visualized by mammography or found on clinical examination. Sestamibi SCM improves the sensitivity of mammography and it detects up to 9% of malignancies not detected by mammography or clinical examination. This testing could impact the management of 16,500 patients in the United States every year. More studies are needed to better define its role in breast cancer detection.     

乳腺肿物99mTc甲氧基异丁基异腈显像的临床价值

目的 评价^99mTc甲氧基异丁基异腈（MIBI）乳腺显像对乳腺癌诊断的价值。方法 对195例和204处乳腺肿物患者分3组进行^99mTc－MIBI显像,并与病理对照,另选择无乳腺疾病者20例作对照组。^99mTc－MIBI在乳腺中有异常浓聚且阈值数大于健侧相对应区10％时为阳性。结果 本研究中乳腺癌病变100处,阳性显像92处;乳腺良性病变70处,阳性显像12处;隐匿性病变34处,阳性显像6处,3处为乳腺癌;对照组20例显像均阴性。^99mTc－MIBI对乳腺疾病的诊断准确率为92．0％,灵敏度为91．8％、特异度为92％、阳性预测值为86％、阴性预测值为92％。结论 ^99mTc－MIBI对乳腺癌的诊断及良恶性病变的鉴别有较高的敏感性和准确性。     

Biopsy of the impalpable breast lesion detected by mammography.

Specimen radiology plays an essential part in the surgical management of the impalpable breast lesion detected by mammography. It also plays a necessary part in the complete pathological examination of the specimen. A method for preoperative localization of the mammographically detected impalpable breast lesion is described.     

Pathology and treatment of impalpable breast lesions.

With the increasing use of mammography, more needle-localized breast biopsies (NLBB) are being done. The purpose of this study was to analyze the pathology of impalpable breast lesions and the impact of NLBB on treatment strategies. From 1985 to 1990, 1,605 NLBB were performed, of which 321 (20%) were malignant. Twenty-five percent of malignant biopsies demonstrated in situ disease only. The average size of all lesions detected was 16 mm, and, for invasive cancer, 12 mm. Eighteen percent of invasive cancers had metastasized to the axillary lymph nodes. Surgical management consisted of mastectomy in 74% of patients and breast conservation treatment (BCT) in 26%. No significant difference in surgical management for women 50 years of age or younger compared with those older than 50 years of age was noted. Although the use of BCT for eligible women is recommended by the National Institutes of Health, it is not widely practiced, possibly reflecting less physician acceptance of BCT. These observations suggest that the detection of smaller, impalpable breast cancers has had no impact on treatment strategies.     

Carbon localisation of impalpable breast lesions

BACKGROUND: Hookwire localisation (HL) is the most widely used technique for excision of impalpable breast lesions. This method has several drawbacks, particularly with logistics. Carbon localisation (CL) is an alternative procedure which is logistically superior to HL, but comparisons of accuracy and costs have not been reported. METHODS: A consecutive case series of all patients from Northwestern BreastScreen undergoing either CL or HL between January 1999 and March 2001. FINDINGS: Of 511 procedures, 219 CLs and 292 HLs were performed. The accuracy of excision did not vary significantly. Where a preoperative diagnosis of malignancy had been made by percutaneous needle biopsy (PNB), the margins were <1mm in 27 of the CL group (18.9%) and 21 of the HL group (29.2%) (P=0.087). Cost analysis was very favourable for CL performed concurrently with PNB since the costs were incremental. INTERPRETATION: At service delivery level, CL is an accurate alternative to HL with better logistics and favourable costs. Nationally, it has the potential to improve the cost effectiveness of breast screening programmes.     

Strategies for localisation of impalpable breast lesions

With advances in the sensitivity of mammographic screening and the broader population of women screened via national programmes. More than 50% of all new breast cancers in the United Kingdom are screen-detected and of the 11,110 invasive breast cancers (78.7 per cent of all UK cancers) detected in the year 2007-2008, 5814 (52.3 per cent) measured 15 mm or less in diameter and were deemed clinically non-palpable.For excision of non-palpable lesions, localisation techniques are currently largely limited to wire-guided localisation with the associated risks of migration, transection and scheduling conflicts.In this review we will describe the current gold-standard of wire-guided localisation (WGL), its associated merits and limitations before reporting on the data available for Radioguided Occult Lesion Localisation (ROLL) and Radiolabeled Seed Localisation (RSL) trials.     

The clinical utility of Tc-99m sestamibi scintimammography in detecting multicentric breast cancer.

The ability to recognize multicentric breast cancer preoperatively would assist in identifying appropriate candidates for breast conservation surgery. Tc-99m scintimammography (SMM) is an adjunct to conventional mammography in identifying selected patients with breast cancer. The purpose of this study is to report the utility of SMM in identifying patients with multicentric breast cancer. Breast cancer patients treated by mastectomy who underwent a preoperative SMM between 1992 and 1999 were identified using the institution's Tumor Registry. The pathology report of each patient was reviewed for multicentric disease defined as an additional focus of cancer within a different quadrant of the breast or greater than 2.5 cm from the dominant tumor mass. Each patient's preoperative SMM was reviewed and compared with the pathologic findings to obtain correlative data. Fifty-eight women treated by mastectomy had preoperative SMM (age range 35-78 years; median 52 years). Pathology revealed infiltrating ductal carcinoma in 49 patients (84.5%), infiltrating lobular carcinoma in five patients (8.6%), ductal carcinoma in situ in three patients (5.1%), and colloid carcinoma in one patient (1.7%). Multicentric disease was present in the specimens of eight patients for a prevalence of 10.3 per cent. SMM was positive for uptake in 36 of 58 patients (sensitivity 62.1%). The sensitivity, specificity, positive predictive value, and negative predictive value of SMM in the detection of multicentric disease were 62.5, 96, 71, and 94 per cent, respectively. Although the overall sensitivity of SMM in the detection of breast cancer is superior to that of conventional mammography and physical examination in identifying multicentric breast cancer it is not an accurate modality for detecting multicentric disease in this study group. However, it may have limited applications in specific cases.     

Percutaneous excisional biopsy of impalpable breast lesions under ultrasound visualization

Within the last ten years, the development of innovative minimally invasive breast biopsy technologies has made a significant impact on the diagnostic evaluation of impalpable breast lesions. The Mammotome minimally invasive biopsy system is a diagnostic tool used under stereotactic or ultrasound guidance. The minimally invasive biopsies for 143 impalpable breast lesions in 86 patients were performed using the B-ultrasound-guided 8-gauge vacuum-assisted Mammotome system at Jinan Military General Hospital. One hundred and forty-three breast lesions in 86 patients were excised completely using this method. The average biopsy procedure time was 17 min (range, 3–45 min). Clinically, suspicious lesions were satisfactorily confirmed by this system. One hundred and twenty-one lesions were diagnosed as fibroadenoma, nineteen lesions as breast adenosis, one lesion as invasive breast cancer, and two lesions as ductal carcinoma in situ. Skin ecchymosis was found in two patients. One hundred and thirty-two impalpable lesions were completely excised, as demonstrated by the follow-up ultrasound examination. The results suggest that the B-ultrasound-guided Mammotome system may be an efficient tool for the diagnosis and treatment of impalpable breast lesions.     

99Tcm-MIBI 亲肿瘤显像对乳腺癌的诊断价值

笔者对43例乳腺肿块患者行双侧乳腺99TCm-MIBI亲肿瘤显像，并将结果与手术肿块切除病理检查对照分析。结果 示43例乳腺肿块中病理检查证实为乳腺癌36例，其中ll例伴同侧腋窝淋巴结转移；良性病变7例。99Tc^MIBI显像真阳性34例，真阴性6例，假阴性2例，假阳性l例。腋窝淋巴结显像阳性7例，占腋窝淋巴结的63．6％(7／11)。99Tc^m-MIBI显像对乳腺癌原发灶诊断的敏感性、特异性和准确率分别是94．4％，85．7％和93．0％。提示99Tc^m-MIBI显像对乳腺癌的诊断有较高的敏感性、特异性和准确率。     

Clinical significance of 99mTc-MIBI breast imaging in the diagnosis of early breast cancer

OBJECTIVE: To find an effective, sensitive, specific and noninvasive diagnostic method for cancer. METHODS: 109 masses from 102 patients with breast lesions smaller than 2 cm in diameter were divided into three groups to undergo 99mtechnetium-methoxyisobutylisonitrile (99mTc-MIBI) imaging. The results were compared with their pathology. Twenty cases without breast lesions were selected as a control group. Abnormal density of 99mTc-MIBI in the breast and a threshold level 10% higher than that in the counterpart of the healthy breast was regarded as positive. RESULTS: Of 32 breast cancers, positive imaging appeared in 25. Negative imaging was found in 31 of 38 benign breast lesions. Of 39 nonpalpable breast lesions, five cases were breast cancers and 34 cases benign. Positive MIBI imaging appeared in all of the breast cancers, while in the benign lesions, four were positive and 30 negative. No positive imaging was found in the control group. The diagnostic accuracy, sensitivity, specificity, positive predictive value and negative predictive value of 99mTc-MIBI were 88.4%, 89.2%, 88.0%, 75.0% and 95.3%, respectively.CONCLUSIONS: 99mTc-MIBI imaging had high sensitivity and accuracy in the diagnosis of breast cancer, as well as in the differentiation between benign and malignant breast lesions. It could provide reliable information in confirming the diagnosis in patients with clinically suspected breast cancer.     

99mTc-甲氧基异丁基异腈显像诊断乳房肿块的临床价值

目的 评价^99mTc-甲氧基异丁基异腈（MIBI）显像鉴别乳房肿块良恶性的价值。方法 对106例乳房肿块行^99mTc-MIBI显像检查,全部病例均经手术治疗,与病理结果比较,结果 106例中乳腺癌56例,显像阳性48例,假阴性主要为肿块较小的乳腺癌;良性病变50例,显像阴性40例,假阳性主要为血供丰富的大纤维腺瘤。该法诊断乳腺癌的灵敏度为85.7%,特异性为80.0%,阳性预告值82.8%、阴性预告值83.3%、总正确诊断率为83.0%。结论 ^99mTx-MIBI显像是鉴别乳房良恶性肿块的有效的、无创性检查方法,但对大纤维腺瘤和较小的恶性肿块诊断作用较差。     

Tc 99m-Sestamibi scintimammography in the differentiation of benign and malignant breast microcalcifications

The capability of the mammography-scintimammography combination to distinguish between benign and malignant isolated clusters of breast microcalcifications is discussed. Scintimammography using Tc 99m-Sestamibi was performed in 97 women with an isolated cluster of microcalcifications on mammograms. Seventy-two women had final histopathologic diagnoses (24 cancer and 48 benign pathology). The other 25 patients had follow-up to 3 years. The results of mammography, scintimammography and mammography-scintimammography combination were divided into five groups, based on the suspicion of malignancy. The sensitivity, specificity, false negative fraction, false positive fraction, predictive positive value, predictive negative value and diagnostic accuracy were calculated varying the diagnostic threshold. The Receiver Operating Characteristic (ROC) statistical technique was employed to compare the diagnostic value of mammography to mammography-scintimammography combination. The area under the ROC curves was calculated by the Wilcoxon statistic without any hypothesis on data distribution. The detected difference between areas under the mammography ROC curve (area=0.854, standard error=0.049) and mammography-scintimammography ROC curve (area=0.897, standard error 0.033) was statistically significant (P>0.05, one tail). The area under a ROC curve represents the probability that a randomly chosen diseased or non-diseased subject could be correctly classified. From this point of view this paper demonstrates that, if properly used, scintimammography can add to mammography in the characterization of an isolated cluster of microcalcifications, even if it is not able to replace FNAB and core biopsy.     

The attitude before subclinical breast lesions on mammography

Mammographic screening and improvement of mammography resolution have resulted in the increasingly frequent identification of small-size mammary lesions that have no clinical expression. If in Western countries, approximately one quarter of breast cancers are discovered when clinically occult, in Romania such cases are rare and, most of the times, discovered merely by chance. Infraclinical mammary lesions identified by mammography pose problems concerning the appropriate response. The paper assesses the various diagnosis and therapy choices as well as the localization techniques to be employed in order to establish the best approach. We describe twelve cases of infraclinical mammary lesions identified by mammography. In two of this cases fine needle aspiration biopsy with cytological examination was used, and in one case we performed core biopsy and histological examination. In those cases, lesion localization has been performed using stereotactic X-ray devices. In nine cases, we performed excisional biopsy with histologic assessment. In four of those cases, the lesions proved to be malignant. Preoperative localization was performed with hookwires placed in the proximity of the lesion under mammographic control. In five of those cases, lesion coordinates have been determined by stereotaxy. Using this technique, we removed, in all cases, the clinical lesions identified by mammography. We believe surgical excision to be the best approach in such lesions. Total removal of the lesion enables a thorough histopathological examination resulting in more accurate diagnosis. Curative surgery is also possible within the same surgical procedure. Unless preoperative localization is performed the surgeon is in the position to excise an image that has no clinical expression. Under this circumstances surgical removal is performed blind, as the lesion is hard to be found even intraoperatory. Preoperative localization provides guidance to the surgeon, ensures removal of the lesion that has been identified by mammography and helps avoids unnecessary mammary resection.