Comparison of Whole-Body (18)F FDG PET/MR Imaging and Whole-Body (18)F FDG PET/CT in Terms of Lesion Detection and Radiation Dose in Patients with Breast Cancer

Comparison of [18F] FDG PET/CT and [18F]FDG PET/MRI in the Detection of Distant Metastases in Breast Cancer: A Meta-Analysis

PURPOSE

This meta-analysis aims to assess and compare the diagnostic effectiveness of [18F] FDG PET/CT and [18F] FDG PET/MRI for distant metastases in breast cancer patients.

METHODS

A comprehensive search of the PubMed and Embase databases was performed to identify relevant articles until September 22, 2023. Studies were eligible to be included if they assessed the diagnostic performance of [18F] FDG PET/CT and/or [18F] FDG PET/MRI in detecting distant metastases of breast cancer patients. The DerSimonian and Laird method was used to assess sensitivity and specificity, and then transformed through the Freeman-Tukey double arcsine transformation.

RESULTS

29 articles consisting of 3779 patients were finally included in this study. The overall sensitivity of [18F] FDG PET/CT in diagnosing distant metastases of breast cancer was 0.96 (95% CI: 0.93-0.98), and the overall specificity was 0.95 (95% CI: 0.92-0.97). The overall sensitivity of [18F] FDG PET/MRI was 1.00 (95% CI: 0.97-1.00), and the specificity was 0.97 (95% CI: 0.94-1.00). The results suggested that [18F] FDG PET/CT and [18F] FDG PET/MRI appears to have similar sensitivity (P = .16) and specificity (P = .30) in diagnosing distant metastases of breast cancer.

CONCLUSIONS

The results of our meta-analysis indicated that [18F] FDG PET/CT and [18F] FDG PET/MRI in diagnosing distant metastases of breast cancer appear to have similar sensitivity and specificity. Patients who have access to only one of these modalities will not have the accuracy of their staging compromised. In clinical practice, both of these imaging techniques have their respective strengths and limitations, and physicians should take these into account when making the most suitable choice for patients.

Diagnosing Bone Metastases in Breast Cancer: A Systematic Review and Network Meta-Analysis on Diagnostic Test Accuracy Studies of 2-[18F]FDG-PET/CT, 18F-NaF-PET/CT, MRI, Contrast-Enhanced CT, and Bone Scintigraphy

This systematic review and network meta-analysis aimed to compare the diagnostic accuracy of 2-[18F]FDG-PET/CT, 18F-NaF-PET/CT, MRI, contrast-enhanced CT, and bone scintigraphy for diagnosing bone metastases in patients with breast cancer. Following PRISMA-DTA guidelines, we reviewed studies assessing 2-[18F]FDG-PET/CT, 18F-NaF-PET/CT, MRI, contrast-enhanced CT, and bone scintigraphy for diagnosing bone metastases in high-stage primary breast cancer (stage III or IV) or known primary breast cancer with suspicion of recurrence (staging or re-staging). A comprehensive search of MEDLINE/PubMed, Scopus, and Embase was conducted until February 2024. Inclusion criteria were original studies using these imaging methods, excluding those focused on AI/machine learning, primary breast cancer without metastases, mixed cancer types, preclinical studies, and lesion-based accuracy. Preference was given to studies using biopsy or follow-up as the reference standard. Risk of bias was assessed using QUADAS-2. Screening, bias assessment, and data extraction were independently performed by two researchers, with discrepancies resolved by a third. We applied bivariate random-effects models in meta-analysis and network meta-analyzed differences in sensitivity and specificity between the modalities. Forty studies were included, with 29 contributing to the meta-analyses. Of these, 13 studies investigated one single modality only. Both 2-[18F]FDG-PET/CT (sensitivity: 0.94, 95% CI: 0.89-0.97; specificity: 0.98, 95% CI: 0.96-0.99), MRI (0.94, 0.82-0.98; 0.93, 0.87-0.96), and 18F-NaF-PET/CT (0.95, 0.85-0.98; 1, 0.93-1) outperformed the less sensitive modalities CE-CT (0.70, 0.62-0.77; 0.98, 0.97-0.99) and bone scintigraphy (0.83, 0.75-0.88; 0.96, 0.87-0.99). The network meta-analysis of multi-modality studies supports the comparable performance of 2-[18F]FDG-PET/CT and MRI in diagnosing bone metastases (estimated differences in sensitivity and specificity, respectively: 0.01, -0.16 - 0.18; -0.02, -0.15 - 0.12). The results from bivariate random effects modelling and network meta-analysis were consistent for all modalities apart from 18F-NaF-PET/CT. We concluded that 2-[18F]FDG-PET/CT and MRI have high and comparable accuracy for diagnosing bone metastases in breast cancer patients. Both outperformed CE-CT and bone scintigraphy regarding sensitivity. Future multimodality studies based on consented thresholds are warranted for further exploration, especially in terms of the potential role of 18F-NaF-PET/CT in bone metastasis diagnosis in breast cancer.

Diagnostic performance of simultaneous PET-MR versus PET-CT in oncology with an overview on clinical utility and referral pattern of PET-MR: a single institutional study

BACKGROUND

PET-Magnetic Resonance (PET-MR) imaging is an upcoming investigative modality with a few installations in Asia and only three in India. PET-Computed Tomography (PET-CT) is an established diagnostic cornerstone for oncological indications but with limited resolution for small lesions due to low soft-tissue contrast and additional radiation exposure.

OBJECTIVE

Our primary objective was to evaluate the diagnostic performance of simultaneous PET-MR and PET-CT in lesion detection in oncological practice. Secondly to assess the referral pattern and study the clinical utility of PET-MR in a university hospital practice.

MATERIALS AND METHODS

A total of 100 consecutive biopsy-proven cancer patients (breast or lung malignancy with suspected metastases) underwent 18 F Fluorodeoxyglucose (FDG) PET-MR and PET-CT for staging as a single injection, double examination protocol. Morphological lesion detection on correlative imaging/histopathology was used as the gold standard. Analysing the referral pattern, a total of 9366 patients underwent simultaneous PET-MR imaging for various indications in the past 5 years since installation.

RESULTS

18 F FDG PET-MR detected 100% of primary tumours in breast/lung carcinoma patients while PET-CT was positive in 96%. Overall accuracy of nodal metastases detection for PET-MR and PET-CT was 96 and 88%, while for distant metastases the accuracy was 100 and 93%, respectively. FDG PET-MR proved more sensitive and specific than PET-CT for regional nodal ( P  = 0.011 and P  < 0.001) and distant metastases detection ( P  = 0.017 and P < 0.001, respectively). Analysing the general referral pattern for PET-MR, the majority were oncology referrals when compared to nononcological indications (66.5, 33.5%). About 66.24% were FDG based, followed by 68 Ga Prostate-Specific Membrane Antigen (PSMA) and dodecane tetraacetic acid (DOTA). The general utility of PET-MR was found incremental in better delineation of small lesions especially in head, neck, liver, brain and gynaecological malignancies.

CONCLUSION

In our past 5 years of PET-MR practice, we found that simultaneous PET-MR is a highly recommended ideal imaging technique for oncological and nononcological indications. It has excellent diagnostic performance with high sensitivity, specificity and accuracy when compared to PET-CT in primary tumour, nodal and distant metastases (TNM) staging in specific subgroup of breast and lung malignancy patients.

Role of [18F]FDG PET/CT in patients with invasive breast carcinoma of no special type: Literature review and comparison between guidelines

PURPOSE

The recently released EANM/SNMMI guideline, endorsed by several important clinical and imaging societies in the field of breast cancer (BC) care (ACR, ESSO, ESTRO, EUSOBI/ESR, EUSOMA), emphasized the role of [18F]FDG PET/CT in management of patients with no special type (NST) BC. This review identifies and summarizes similarities, discrepancies and novelties of the EANM/SNMMI guideline compared to NCCN, ESMO and ABC recommendations.

METHODS

The EANM/SNMMI guideline was based on a systematic literature search and the AGREE tool. The level of evidence was determined according to NICE criteria, and 85 % agreement or higher was reached regarding each statement. Comparisons with NCCN, ESMO and ABC guidelines were examined for specific clinical scenarios in patients with early stage through advanced and metastatic BC.

RESULTS

Regarding initial staging of patients with NST BC, [18F]FDG PET/CT is the preferred modality in the EANM-SNMMI guideline, showing superiority as a single modality to a combination of contrast-enhanced CT of thorax-abdomen-pelvis plus bone scan in head-to-head comparisons and a randomized study. Its use is recommended in patients with clinical stage IIB or higher and may be useful in certain stage IIA cases of NST BC. In NCCN, ESMO, and ABC guidelines, [18F]FDG PET/CT is instead recommended as complementary to conventional imaging to solve inconclusive findings, although ESMO and ABC also suggest [18F]FDG PET/CT can replace conventional imaging for staging patients with high-risk and metastatic NST BC. During follow up, NCCN and ESMO only recommend diagnostic imaging if there is suspicion of recurrence. Similarly, EANM-SNMMI states that [18F]FDG PET/CT is useful to detect the site and extent of recurrence only when there is clinical or laboratory suspicion of recurrence, or when conventional imaging methods are equivocal. The EANM-SNMMI guideline is the first to emphasize a role of [18F]FDG PET/CT for assessing early metabolic response to primary systemic therapy, particularly for HER2+ BC and TNBC. In the metastatic setting, EANM-SNMMI state that [18F]FDG PET/CT may help evaluate bone metastases and determine early response to treatment, in agreement with guidelines from ESMO.

CONCLUSIONS

The recently released EANM/SNMMI guideline reinforces the role of [18F]FDG PET/CT in the management of patients with NST BC supported by extensive evidence of its utility in several clinical scenarios.

Head-to-Head Comparison of the Diagnostic Performance of FDG PET/CT and FDG PET/MRI in Patients With Cancer: A Systematic Review and Meta-Analysis

BACKGROUND. The available evidence on the use of FDG PET/MRI performed using an integrated system in patients with cancer has grown substantially. OBJECTIVE. The purpose of this study was to perform a systematic review and meta-analysis comparing the diagnostic performance of FDG PET/CT and FDG PET/MRI in patients with cancer. EVIDENCE ACQUISITION. MEDLINE, Embase, and the Cochrane Database of Systematic Reviews were searched for studies reporting a head-to-head comparison of the diagnostic performance of FDG PET/CT and FDG PET/MRI in patients with cancer from July 1, 2015, to January 25, 2023. The two modalities' diagnostic performance was summarized, stratified by performance end point. For end points with sufficient data, a meta-analysis was performed using bivariate modeling to produce summary estimates of pooled sensitivity and specificity. For the remaining end points, reported performance in individual studies was recorded. EVIDENCE SYNTHESIS. The systematic review included 29 studies with a total of 1656 patients. For patient-level detection of regional nodal metastases (five studies), pooled sensitivity and specificity for PET/MRI were 88% (95% CI, 74-95%) and 92% (95% CI, 71-98%), respectively, and for PET/CT were 86% (95% CI, 70-94%) and 86% (95% CI, 68-95%). For lesion-level detection of recurrence and/or metastases (five studies), pooled sensitivity and specificity for PET/MRI were 94% (95% CI, 78-99%) and 83% (95% CI, 76-88%), respectively, and for PET/CT were 91% (95% CI, 77-96%) and 81% (95% CI, 72-88%). In individual studies not included in the meta-analysis, PET/MRI in comparison with PET/CT showed staging accuracy in breast cancer of 98.0% versus 74.5% and in colorectal cancer of 96.2% versus 69.2%; sensitivity for primary tumor detection in cervical cancer of 93.2% versus 66.2%; and sensitivity, specificity, and accuracy for lesion-level liver metastasis detection of 91.1-98.0% versus 42.3-71.1%, 100.0% versus 83.3-98.6%, and 96.5-98.2% versus 44.7-86.7%, respectively. In three studies, management was more commonly impacted by information from PET/MRI (5.2-11.1%) than PET/CT (0.0-2.6%). CONCLUSION. PET/MRI showed comparable or superior diagnostic performance versus PET/CT across a range of cancers and end points. CLINICAL IMPACT. The findings help to identify clinical settings where PET/MRI may provide clinical benefit for oncologic evaluation. TRIAL REGISTRATION. Prospective Register of Systematic Reviews CRD42023433857.

[18F]FDG PET/CT versus [18F]FDG PET/MRI in the evaluation of liver metastasis in patients with primary cancer: A head-to-head comparative meta-analysis

PURPOSE

This meta-analysis aimed to compare the diagnostic effectiveness of [18F]FDG PET/CT with that of [18F]FDG PET/MRI in terms of identifying liver metastasis in patients with primary cancer.

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched, and studies evaluating the diagnostic efficacy of [18F]FDG PET/CT and [18F]FDG PET/MRI in patients with liver metastasis of primary cancer were included. We used a random effects model to analyze their sensitivity and specificity. Subgroup analyses and corresponding meta-regressions focusing on race, image analysis, study design, and analysis methodologies were conducted. Cochrane Q and I2 statistics were used to assess intra-group and inter-group heterogeneity.

RESULTS

Seven articles with 343 patients were included in this meta-analysis. The sensitivity of [18F]FDG PET/CT was 0.82 (95 % CI: 0.63-0.96), and that of [18F]FDG PET/MRI was 0.91 (95 % CI: 0.82-0.98); there was no significant difference between the two methods (P = 0.32). Similarly, both methods showed equal specificity: 1.00 (95 % CI: 0.95-1.00) for [18F]FDG PET/CT and 1.00 (95 % CI: 0.96-1.00) for [18F]FDG PET/MRI, and thus, there was no significant difference between the methods (P = 0.41). Furthermore, the subgroup analyses revealed no differences. Meta-regression analysis revealed that race was a potential source of heterogeneity for [18F]FDG PET/CT (P = 0.01), while image analysis and contrast agent were found to be potential sources of heterogeneity for [18F]FDG PET/MRI (P = 0.02).

CONCLUSIONS

[18F]FDG PET/MRI has similar sensitivity and specificity to [18F]FDG PET/CT for detecting liver metastasis of primary cancer in both the general population and in subgroups. [18F]FDG PET/CT may be a more cost-effective option. However, the conclusions of this meta-analysis are tentative due to the limited number of studies included, and further research is necessary for validation.

PET Molecular Imaging in Breast Cancer: Current Applications and Future Perspectives

Positron emission tomography (PET) plays a crucial role in breast cancer management. This review addresses the role of PET imaging in breast cancer care. We focus primarily on the utility of 18F-fluorodeoxyglucose (FDG) PET in staging, recurrence detection, and treatment response evaluation. Furthermore, we delve into the growing interest in precision therapy and the development of novel radiopharmaceuticals targeting tumor biology. This includes discussing the potential of PET/MRI and artificial intelligence in breast cancer imaging, offering insights into improved diagnostic accuracy and personalized treatment approaches.

Extended MRI-based PET motion correction for cardiac PET/MRI

PURPOSE

A 2D image navigator (iNAV) based 3D whole-heart sequence has been used to perform MRI and PET non-rigid respiratory motion correction for hybrid PET/MRI. However, only the PET data acquired during the acquisition of the 3D whole-heart MRI is corrected for respiratory motion. This study introduces and evaluates an MRI-based respiratory motion correction method of the complete PET data.

METHODS

Twelve oncology patients scheduled for an additional cardiac 18F-Fluorodeoxyglucose (18F-FDG) PET/MRI and 15 patients with coronary artery disease (CAD) scheduled for cardiac 18F-Choline (18F-FCH) PET/MRI were included. A 2D iNAV recorded the respiratory motion of the myocardium during the 3D whole-heart coronary MR angiography (CMRA) acquisition (~ 10 min). A respiratory belt was used to record the respiratory motion throughout the entire PET/MRI examination (~ 30-90 min). The simultaneously acquired iNAV and respiratory belt signal were used to divide the acquired PET data into 4 bins. The binning was then extended for the complete respiratory belt signal. Data acquired at each bin was reconstructed and combined using iNAV-based motion fields to create a respiratory motion-corrected PET image. Motion-corrected (MC) and non-motion-corrected (NMC) datasets were compared. Gating was also performed to correct cardiac motion. The SUVmax and TBRmax values were calculated for the myocardial wall or a vulnerable coronary plaque for the 18F-FDG and 18F-FCH datasets, respectively.

RESULTS

A pair-wise comparison showed that the SUVmax and TBRmax values of the motion corrected (MC) datasets were significantly higher than those for the non-motion-corrected (NMC) datasets (8.2 ± 1.0 vs 7.5 ± 1.0, p < 0.01 and 1.9 ± 0.2 vs 1.2 ± 0.2, p < 0.01, respectively). In addition, the SUVmax and TBRmax of the motion corrected and gated (MC_G) reconstructions were also higher than that of the non-motion-corrected but gated (NMC_G) datasets, although for the TBRmax this difference was not statistically significant (9.6 ± 1.3 vs 9.1 ± 1.2, p = 0.02 and 2.6 ± 0.3 vs 2.4 ± 0.3, p = 0.16, respectively). The respiratory motion-correction did not lead to a change in the signal to noise ratio.

CONCLUSION

The proposed respiratory motion correction method for hybrid PET/MRI improved the image quality of cardiovascular PET scans by increased SUVmax and TBRmax values while maintaining the signal-to-noise ratio. Trial registration METC162043 registered 01/03/2017.

Quarter-Century Transformation of Oncology: Positron Emission Tomography for Patients with Breast Cancer

PET radiotracers have become indispensable in the care of patients with breast cancer. 18F-fluorodeoxyglucose has become the preferred method of many oncologists for systemic staging of breast cancer at initial diagnosis, detecting recurrent disease, and for measuring treatment response after therapy. 18F-Sodium Fluoride is valuable for detection of osseous metastases. 18F-fluoroestradiol is now FDA-approved with multiple appropriate clinical uses. There are multiple PET radiotracers in clinical trials, which may add utility of PET imaging for patients with breast cancer in the future. This article will describe the advances during the last quarter century in PET for patients with breast cancer.

The use of PET/MRI in radiotherapy

Positron emission tomography/magnetic resonance imaging (PET/MRI) is a hybrid imaging technique that quantitatively combines the metabolic and functional data from positron emission tomography (PET) with anatomical and physiological information from MRI. As PET/MRI technology has advanced, its applications in cancer care have expanded. Recent studies have demonstrated that PET/MRI provides unique advantages in the field of radiotherapy and has become invaluable in guiding precision radiotherapy techniques. This review discusses the rationale and clinical evidence supporting the use of PET/MRI for radiation positioning, target delineation, efficacy evaluation, and patient surveillance.Critical relevance statement This article critically assesses the transformative role of PET/MRI in advancing precision radiotherapy, providing essential insights into improved radiation positioning, target delineation, efficacy evaluation, and patient surveillance in clinical radiology practice.Key points• The emergence of PET/MRI will be a key bridge for precise radiotherapy.• PET/MRI has unique advantages in the whole process of radiotherapy.• New tracers and nanoparticle probes will broaden the use of PET/MRI in radiation.• PET/MRI will be utilized more frequently for radiotherapy.

Diagnostic performance of whole-body [18F]FDG PET/MR in cancer M staging: A systematic review and meta-analysis

OBJECTIVES

To calculate the pooled diagnostic performances of whole-body [18F]FDG PET/MR in M staging of [18F]FDG-avid cancer entities.

METHODS

A diagnostic meta-analysis was conducted on the [18F]FDG PET/MR in M staging, including studies: (1) evaluated [18F]FDG PET/MR in detecting distant metastasis; (2) compared[ 18F]FDG PET/MR with histopathology, follow-up, or asynchronous multimodality imaging as the reference standard; (3) provided data for the whole-body evaluation; (4) provided adequate data to calculate the meta-analytic performances. Pooled performances were calculated with their confidence interval. In addition, forest plots, SROC curves, and likelihood ratio scatterplots were drawn. All analyses were performed using STATA 16.

RESULTS

From 52 eligible studies, 2289 patients and 2072 metastases were entered in the meta-analysis. The whole-body pooled sensitivities were 0.95 (95%CI: 0.91-0.97) and 0.97 (95%CI: 0.91-0.99) at the patient and lesion levels, respectively. The pooled specificities were 0.99 (95%CI: 0.97-1.00) and 0.97 (95%CI: 0.90-0.99), respectively. Additionally, subgroup analyses were performed. The calculated pooled sensitivities for lung, gastrointestinal, breast, and gynecological cancers were 0.90, 0.93, 1.00, and 0.97, respectively. The pooled specificities were 1.00, 0.98, 0.97, and 1.00, respectively. Furthermore, the pooled sensitivities for non-small cell lung, colorectal, and cervical cancers were 0.92, 0.96, and 0.86, respectively. The pooled specificities were 1.00, 0.95, and 1.00, respectively.

CONCLUSION

[18F]FDG PET/MR was a highly accurate modality in M staging in the reported [18F]FDG-avid malignancies. The results showed high sensitivity and specificity in each reviewed malignancy type. Thus, our findings may help clinicians and patients to be confident about the performance of [18F]FDG PET/MR in the clinic.

CLINICAL RELEVANCE STATEMENT

Although [18F]FDG PET/MR is not a routine imaging technique in current guidelines, mostly due to its availability and logistic issues, our findings might add to the limited evidence regarding its performance, showing a sensitivity of 0.95 and specificity of 0.97.

KEY POINTS

• The whole-body [18F]FDG PET/MR showed high accuracy in detecting distant metastases at both patient and lesion levels. • The pooled sensitivities were 95% and 97% and pooled specificities were 99% and 97% at patient and lesion levels, respectively. • The results suggested that 18F-FDG PET/MR was a strong modality in the exclusion and confirmation of distant metastases.

The Clinical Added Value of Breast Cancer Imaging Using Hybrid PET/MR Imaging

Dedicated MR imaging is highly performant for the evaluation of the primary lesion and should regularly be added to whole-body PET/MR imaging for the initial staging. PET/MR imaging is highly sensitive for the detection of nodal involvement and could be combined with the high specificity of axillary second look ultrasound for the confirmation of the N staging. For M staging, with the exception of lung lesions, PET/MR imaging is superior to PET/computed tomography, at half the radiation dose. The predictive value of multiparametric imaging with PET/MR imaging holds promise to improve through radiomics and artificial intelligence.

Update on Positron Emission Tomography/Magnetic Resonance Imaging: Cancer and Inflammation Imaging in the Clinic

Hybrid PET/MRI is highly valuable, having made significant strides in overcoming technical challenges and offering unique advantages such as reduced radiation, precise data coregistration, and motion correction. Growing evidence highlights the value of PET/MRI in broad clinical aspects, including inflammatory and oncological imaging in adults, pregnant women, and pediatrics, potentially surpassing PET/CT. This newly integrated solution may be preferred over PET/CT in many clinical conditions. However, further technological advancements are required to facilitate its broader adoption as a routine diagnostic modality.

Comprehensive assessment of molecular function, tissue characterization, and hemodynamic performance by non-invasive hybrid imaging: Potential role of cardiac PETMR

Noninvasive cardiovascular imaging plays a key role in diagnosis and patient management including monitoring treatment efficacy. The usefulness of noninvasive cardiovascular imaging has been extensively studied and shown to have high diagnostic reliability and prognostic significance, while the nondiagnostic results frequently encountered with single imaging modality require complementary or alternative imaging techniques. Hybrid cardiac imaging was initially introduced to integrate anatomical and functional information to enhance the diagnostic performance, and lately employed as a strategy for comprehensive assessment of the underlying pathophysiology of diseases. More recently, the utility of computed tomography has grown in diversity, and emerged from being an exploratory technique allowing functional measurement such as stress dynamic perfusion. Cardiac magnetic resonance imaging (CMR) is widely accepted as a robust tool for evaluation of cardiac function, fibrosis, and edema, yielding high spatial resolution and soft-tissue contrast. However, the use of intravenous contrast materials is typically required for accurate diagnosis with these imaging modalities, despite the associated risk of renal toxicity. Nuclear cardiology, established as a molecular imaging technique, has advantages in visualization of the disease-specific biological process at cellular level using numerous probes without requiring contrast materials. Various imaging modalities should be appropriately used sequentially to assess concomitant disease and the progression over time. Therefore, simultaneous evaluation combining high spatial resolution and disease-specific imaging probe is a useful approach to identify the regional activity and the stage of the disease. Given the recent advance and potential of multiparametric CMR and novel nuclide tracers, hybrid positron emission tomography MR is becoming an ideal tool for disease-specific imaging.

Metabolic Positron Emission Tomography in Breast Cancer

Metabolic PET, most commonly 18F-fluorodeoxyglucose (FDG) PET/computed tomography (CT), has had a major impact on the imaging of breast cancer and can have important clinical applications in appropriate patients. While limited for screening, FDG PET/CT outperforms conventional imaging in locally advanced breast cancer. FDG PET/CT is more sensitive than conventional imaging in assessing treatment response, accurately predicting complete response or nonresponse in early-stage cases. It also aids in determining disease extent and treatment response in the metastatic setting. Further research, including randomized controlled trials with FDG and other metabolic agents such as fluciclovine, is needed for optimal breast cancer imaging.

Comparing the diagnostic efficacy of [18F]FDG PET/CT and [18F]FDG PET/MRI for detecting bone metastases in breast cancer: a meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the comparative diagnostic efficacy of [18F]FDG PET/CT and [18F] FDG PET/MRI in detecting bone metastases in breast cancer patients.

METHODS

An extensive search was conducted in the PubMed, Embase, Web of Science, and Cochrane Library databases to identify available publications up to February 2023. Studies were included if they evaluated the diagnostic efficacy of [18F]FDG PET/CT and [18F]FDG PET/MRI in patients with breast cancer bone metastases. Sensitivity and specificity were assessed using the DerSimonian and Laird method, followed by transformation via the Freeman-Tukey double inverse sine transformation.

RESULTS

16 articles (including 4 head-to-head comparison articles) involving 1,261 patients were included in the meta-analysis. The overall sensitivity of [18F]FDG PET/CT in patient-based analysis, lesion-based analysis, and head-to-head comparison were 0.73, 0.89, and 0.87, respectively, while the overall sensitivity of [18F]FDG PET/MRI were 0.99, 0.99, and 0.99. The results indicated that [18F]FDG PET/MRI appears to a higher sensitivity in comparison to [18F]FDG PET/CT(all P < 0.05). In contrast, the overall specificity of [18F]FDG PET/CT in patient-based analysis, lesion-based analysis, and head-to-head comparison were 1.00, 0.99, and 1.00, respectively, while the overall specificity of [18F]FDG PET/MRI were 1.00, 0.99, and 0.98. These results suggested that [18F]FDG PET/CT has a similar level of specificity compared to [18F]FDG PET/MRI.

CONCLUSIONS

Our meta-analysis indicates that [18F]FDG PET/MRI demonstrates superior sensitivity and similar specificity to [18F]FDG PET/CT in detecting bone metastases in breast cancer patients. Further prospective research is required to confirm these findings and assess the clinical application of these techniques.

PET/MRI in Gynecologic Malignancy

Patients with gynecologic malignancies often require a multimodality imaging approach for initial staging, treatment response assessment, and surveillance. MRI imaging and PET are two well-established and widely accepted modalities in this setting. Although PET and MRI imaging are often acquired separately on two platforms (a PET/computed tomography [CT] and an MRI imaging scanner), hybrid PET/MRI scanners offer the potential for comprehensive disease assessment in one visit. Gynecologic malignancies have been one of the most successful areas for implementation of PET/MRI. This article provides an overview of the role of this platform in the care of patients with gynecologic malignancies.

Imaging in metastatic breast cancer, CT, PET/CT, MRI, WB-DWI, CCA: review and new perspectives

BACKGROUND

Breast cancer is the most frequent cancer in women and remains the second leading cause of death in Western countries. It represents a heterogeneous group of diseases with diverse tumoral behaviour, treatment responsiveness and prognosis. While major progress in diagnosis and treatment has resulted in a decline in breast cancer-related mortality, some patients will relapse and prognosis in this cohort of patients remains poor. Treatment is determined according to tumor subtype; primarily hormone receptor status and HER2 expression. Menopausal status and site of disease relapse are also important considerations in treatment protocols.

MAIN BODY

Staging and repeated evaluation of patients with metastatic breast cancer are central to the accurate assessment of disease extent at diagnosis and during treatment; guiding ongoing clinical management. Advances have been made in the diagnostic and therapeutic fields, particularly with new targeted therapies. In parallel, oncological imaging has evolved exponentially with the development of functional and anatomical imaging techniques. Consistent, reproducible and validated methods of assessing response to therapy is critical in effectively managing patients with metastatic breast cancer.

CONCLUSION

Major progress has been made in oncological imaging over the last few decades. Accurate disease assessment at diagnosis and during treatment is important in the management of metastatic breast cancer. CT (and BS if appropriate) is generally widely available, relatively cheap and sufficient in many cases. However, several additional imaging modalities are emerging and can be used as adjuncts, particularly in pregnancy or other diagnostically challenging cases. Nevertheless, no single imaging technique is without limitation. The authors have evaluated the vast array of imaging techniques - individual, combined parametric and multimodal - that are available or that are emerging in the management of metastatic breast cancer. This includes WB DW-MRI, CCA, novel PET breast cancer-epitope specific radiotracers and radiogenomics.

Diagnostic Performance of PET/MRI in Breast Cancer: A Systematic Review and Bayesian Bivariate Meta-analysis

INTRODUCTION

By performing a systematic review and meta-analysis, the diagnostic value of ¹⁸F-FDG PET/MRI in breast lesions, lymph nodes, and distant metastases was assessed, and the merits and demerits of PET/MRI in the application of breast cancer were comprehensively reviewed.

METHODS

Breast cancer-related studies using ¹⁸F-FDG PET/MRI as a diagnostic tool published before September 12, 2022 were included. The pooled sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the curve (AUC) were calculated using Bayesian bivariate meta-analysis in a lesion-based and patient-based manner.

RESULTS

We ultimately included 24 studies (including 1723 patients). Whether on a lesion-based or patient-based analysis, PET/MRI showed superior overall pooled sensitivity (0.95 [95% CI: 0.92-0.98] & 0.93 [95% CI: 0.88-0.98]), specificity (0.94 [95% CI: 0.90-0.97] & 0.94 [95% CI: 0.92-0.97]), LDOR (5.79 [95% CI: 4.95-6.86] & 5.64 [95% CI: 4.58-7.03]) and AUC (0.98 [95% CI: 0.94-0.99] & 0.98[95% CI: 0.92-0.99]) for diagnostic applications in breast cancer. In the specific subgroup analysis, PET/MRI had high pooled sensitivity and specificity for the diagnosis of breast lesions and distant metastatic lesions and was especially excellent for bone lesions. PET/MRI performed poorly for diagnosing axillary lymph nodes but was better than for lymph nodes at other sites (pooled sensitivity, specificity, LDOR, AUC: 0.86 vs. 0.58, 0.90 vs. 0.82, 4.09 vs. 1.98, 0.89 vs. 0.84).

CONCLUSION

¹⁸F-FDG PET/MRI performed excellently in diagnosing breast lesions and distant metastases. It can be applied to the initial diagnosis of suspicious breast lesions, accurate staging of breast cancer patients, and accurate restaging of patients with suspected recurrence.

18F-FDG PET/MRI in Detection of Pulmonary Malignancies: A Systematic Review and Meta-Analysis

Background There have been conflicting results regarding fluorine 18-labeled fluorodeoxyglucose (¹⁸F-FDG) PET/MRI diagnostic performance in lung malignant neoplasms. Purpose To evaluate the diagnostic performance of ¹⁸F-FDG PET/MRI for the detection of pulmonary malignant neoplasms. Materials and Methods A systematic search was conducted within the Scopus, Web of Science, and PubMed databases until December 31, 2021. Published original articles that met the following criteria were considered eligible for meta-analysis: (a) detecting malignant lesions in the lung, (b) comparing ¹⁸F-FDG PET/MRI with a valid reference standard, and (c) providing data for the meta-analytic calculations. A hierarchical method was used to pool the performances. The bivariate model was used to find the summary points and 95% CIs. The hierarchical summary receiver operating characteristic model was used to draw the summary receiver operating characteristic curve and calculate the area under the curve. The Higgins I² statistic and Cochran Q test were used for heterogeneity assessment. Results A total of 43 studies involving 1278 patients met the inclusion criteria and were included in the meta-analysis. ¹⁸F-FDG PET/MRI had a pooled sensitivity and specificity of 96% (95% CI: 84, 99) and 100% (95% CI: 98, 100), respectively. ¹⁸F-FDG PET/CT had a pooled sensitivity and specificity of 99% (95% CI: 61, 100) and 99% (95% CI: 94, 100), respectively, which were comparable with those of ¹⁸F-FDG PET/MRI. At meta-regression, studies in which contrast media (P = .03) and diffusion-weighted imaging (P = .04) were used as a part of a pulmonary ¹⁸F-FDG PET/MRI protocol showed significantly higher sensitivities. Conclusion Fluorine 18-labeled fluorodeoxyglucose (¹⁸F-FDG) PET/MRI was found to be accurate and comparable with ¹⁸F-FDG PET/CT in the detection of malignant pulmonary lesions, with significantly improved sensitivity when advanced acquisition protocols were used. © RSNA, 2023 Supplemental material is available for this article.

Comparison of whole-body 18F-FDG PET/CT and PET/MRI for distant metastases in patients with malignant tumors: a meta-analysis

BACKGROUND

As a first-line imaging modality, whole-body fluorine-18 fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) and 18F-FDG PET/magnetic resonance imaging (MRI) had been widely applied in clinical practice. However, 18F-FDG PET/MRI may be superior to PET/CT for the diagnosis of distant metastases in patients with advanced-stage. Therefore, it is timely and important to systematically determine the diagnostic accuracy of 18F-FDG PET/MRI compared with that of 18F-FDG PET/CT for the diagnosis of distant metastases.

METHODS

This study aimed to compare the diagnostic accuracy of 18F-FDG PET/CT and PET/MRI for the diagnosis of distant metastases in patients with malignant tumors. Relevant studies using both 18F-FDG PET/CT and PET/MRI for assessment of distant metastases in patients with malignant tumors were searched in PubMed, Embase, The Cochrane Library, and Scopus from January 2010 to November 2023. Two reviewers independently selected studies according to the inclusion and exclusion criteria. A reviewer extracted relevant data and assessed the quality of the eligible studies. The pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and area under the summary receiver operating characteristic curve (AUC) for 18F-FDG PET/CT and PET/MRI were analyzed. Subgroup analysis was performed.

RESULTS

Across 14 studies (1042 patients), 18F-FDG PET/MRI had a higher sensitivity (0.87 versus 0.81), AUC value (0.98 versus 0.95), and similar specificity (0.97 versus 0.97), than PET/CT for detecting distant metastases. In 3 studies of breast cancer (182 patients), 18F-FDG PET/MRI had a higher sensitivity (0.95 versus 0.87) and specificity (0.96 versus 0.94) than PET/CT. In 5 studies of lung cancer (429 patients), 18F-FDG PET/CT had a higher sensitivity (0.87 versus 0.84) and a lower specificity (0.95 versus 0.96) to PET/MRI.

CONCLUSIONS

18F-FDG PET/MRI and PET/CT both performed well as detectors of distant metastases in patients with malignant tumors, and the former has higher sensitivity. The subgroup analysis highlights that 18F-FDG PET/MRI and PET/CT hold different advantages for distant metastases staging in different tumors, PET/MRI has a higher accuracy in patients with breast cancer patients, while PET/CT has a higher accuracy in patients with lung cancer.

The progress of PET/MRI in clinical management of patients with pancreatic malignant lesions

Recently, the morbidity and mortality of pancreatic cancer have been increasing year by year. Because of its deep anatomical location and because most presented patients often suffer from abdominal pain or jaundice, it is difficult to diagnose pancreatic cancer at an early stage, leading to late clinical stage and poor prognosis. integrated positron emission tomography/magnetic resonance imaging (PET/MRI) fusion imaging not only has the characteristics of high resolution and multi-parameter imaging of MRI, but also combines the high sensitivity and the semi-quantitative characteristics of PET. In addition, the continuous development of novel MRI imaging and PET imaging biomarkers provide a unique and precise research direction for future pancreatic cancer research. This review summarizes the value of PET/MRI in the diagnosis, staging, efficacy monitoring, and prognosis evaluation of pancreatic cancer, and prognosis for developing emerging imaging agents and artificial intelligence radiomics in pancreatic cancer.

PET/MR imaging in gynecologic cancer: tips for differentiating normal gynecologic anatomy and benign pathology versus cancer

Positron emission tomography/magnetic resonance imaging (PET/MR) is used in the pre-treatment and surveillance settings to evaluate women with gynecologic malignancies, including uterine, cervical, vaginal and vulvar cancers. PET/MR combines the excellent spatial and contrast resolution of MR imaging for gynecologic tissues, with the functional metabolic information of PET, to aid in a more accurate assessment of local disease extent and distant metastatic disease. In this review, the optimal protocol and utility of whole-body PET/MR imaging in patients with gynecologic malignancies will be discussed, with an emphasis on the advantages of PET/MR over PET/CT and how to differentiate normal or benign gynecologic tissues from cancer in the pelvis.

Lung Nodules Missed in Initial Staging of Breast Cancer Patients in PET/MRI-Clinically Relevant?

Simple Summary

Image-based primary staging in women with newly-diagnosed breast cancer is important to exclude distant metastases, which affect up to 10% of women. The increasing implementation of [¹⁸F]FDG-PET/MRI as a radiation-saving primary staging tool bears the risk of missing lung nodules. Thus, chest CT serves as the diagnostic of choice for the detection and classification of pulmonary nodules. The aim of this study was the evaluation of the clinical relevance of missed lung nodules at initial staging of breast cancer patients in [¹⁸F]FDG-PET/MRI compared with CT. We demonstrated in an homogeneous population of 152 patients that all patients with newly-diagnosed breast cancer and clinically-relevant lung nodules were detected at initial [¹⁸F]FDG-PET/MRI staging. However, due to the lower sensitivity of MRI in detecting lung nodules, a small proportion of clinically-relevant lung nodules were missed. Thus, a supplemental low-dose chest CT after neoadjuvant therapy should be considered for backup.

Abstract

Purpose: The evaluation of the clinical relevance of missed lung nodules at initial staging of breast cancer patients in [¹⁸F]FDG-PET/MRI compared with CT. Methods: A total of 152 patients underwent an initial whole-body [¹⁸F]FDG-PET/MRI and a thoracoabdominal CT for staging. Presence, size, shape and location for each lung nodule in [¹⁸F]FDG-PET/MRI was noted. The reference standard was established by taking initial CT and follow-up imaging into account (a two-step approach) to identify clinically-relevant lung nodules. Patient-based and lesion-based data analysis was performed. Results: No patient with clinically-relevant lung nodules was missed on a patient-based analysis with MRI VIBE, while 1/84 females was missed with MRI HASTE (1%). Lesion-based analysis revealed 4/96 (4%, VIBE) and 8/138 (6%, HASTE) missed clinically-relevant lung nodules. The average size of missed lung nodules was 3.2 mm ± 1.2 mm (VIBE) and 3.6 mm ± 1.4 mm (HASTE) and the predominant location was in the left lower quadrant and close to the hilum. Conclusion: All patients with newly-diagnosed breast cancer and clinically-relevant lung nodules were detected at initial [¹⁸F]FDG-PET/MRI staging. However, due to the lower sensitivity in detecting lung nodules, a small proportion of clinically-relevant lung nodules were missed. Thus, supplemental low-dose chest CT after neoadjuvant therapy should be considered for backup.

Update on the Use of PET/MRI Contrast Agents and Tracers in Brain Oncology: A Systematic Review

The recent advancements in hybrid positron emission tomography–magnetic resonance imaging systems (PET/MRI) have brought massive value in the investigation of disease processes, in the development of novel treatments, in the monitoring of both therapy response and disease progression, and, not least, in the introduction of new multidisciplinary molecular imaging approaches. While offering potential advantages over PET/CT, the hybrid PET/MRI proved to improve both the image quality and lesion detectability. In particular, it showed to be an effective tool for the study of metabolic information about lesions and pathological conditions affecting the brain, from a better tumor characterization to the analysis of metabolic brain networks. Based on the PRISMA guidelines, this work presents a systematic review on PET/MRI in basic research and clinical differential diagnosis on brain oncology and neurodegenerative disorders. The analysis includes literature works and clinical case studies, with a specific focus on the use of PET tracers and MRI contrast agents, which are usually employed to perform hybrid PET/MRI studies of brain tumors. A systematic literature search for original diagnostic studies is performed using PubMed/MEDLINE, Scopus and Web of Science. Patients, study, and imaging characteristics were extracted from the selected articles. The analysis included acquired data pooling, heterogeneity testing, sensitivity analyses, used tracers, and reported patient outcomes. Our analysis shows that, while PET/MRI for the brain is a promising diagnostic method for early diagnosis, staging and recurrence in patients with brain diseases, a better definition of the role of tracers and imaging agents in both clinical and preclinical hybrid PET/MRI applications is needed and further efforts should be devoted to the standardization of the contrast imaging protocols, also considering the emerging agents and multimodal probes.

Internal mammary lymph node metastasis in breast cancer patients based on anatomical imaging and functional imaging

Internal mammary lymph node (IMLN) metastasis forms part of the clinical node classification for primary breast cancer, which influences the treatment strategy. However, because of the IMLNs' complicated anatomical structures and relationships with adjacent structures, IMLN biopsy or resection is associated with a limited improvement in prognosis and a high complication rate. The positivity rate also varies broadly according to imaging modality, and there is a low rate of agreement between the imaging and pathological diagnoses, which creates imprecision in the preoperative staging. The IMLN positivity rate also varies remarkably, and there are no clear, accurate, and non-invasive modalities for diagnosing the pre-mastectomy IMLN status. Nevertheless, medical imaging modalities continue to evolve, with functional imaging and image-guided thoracoscopic biopsy of sentinel IMLNs being well established. Thus, personalized decision-making and treatment selection should be based on the modality-specific differences in the diagnosis of IMLN metastasis/recurrence and the patient's specific risk factors.

DESIGN, COMMISSIONING AND OPERATION OF PROGRAMMABLE DRAINAGE SYSTEM FOR PET-CT: AN OPTIMIZED APPROACH TO PROTECT PERSONNEL AND ENVIRONMENT IN NUCLEAR MEDICINE FACILITIES

Nuclear medicine facilities are considered one of the most important practices associated with potential radiological risks to personnel and the environment due to the significant amounts of solid and liquid radioactive waste generated from these facilities. Whenever possible and applicable, the licensee shall apply the most up-to-date technological advances to ensure that such radioactive waste is safely discharged to the public sewage. To date, there is no specific technical safety requirement endorsed by regulatory body in Egypt regarding drainage system design for nuclear medicine facilities. This paper discusses the design, commissioning and operation of a programmable drainage system in a Positron Emission Tomography/Computed Tomography (PET-CT) unit for collecting and draining sewage contaminated with the radioactive isotope 18F. The system operates automatically without the need for human intervention. The system has been tested using clean water and found to be working efficiently in accordance with the design parameters. The proposed system concept can be applied in other nuclear medicine facilities after scaling it up/down according to all radionuclides in use and the expected volume of associated radioactive waste. Based on the system's demonstrated performance, regulatory bodies are highly recommended to embrace such approach as a safety requirement to assist the licensees in complying with the safety standards during the planning and construction of PET-CT facilities.

[18F]FDG PET/MRI in the follow-up of hepatocellular carcinoma after liver transplantation

BACKGROUND

There is limited evidence regarding the application of [18F] fluorodeoxyglucose (FDG)-PET/MRI in patients with a suspected clinical recurrence, who underwent liver transplantation for hepatocellular carcinoma (HCC). Therefore, we compared the accuracy of PET/MR and standard-of-care (SOC) imaging in these patients.

METHODS

We retrospectively reviewed 26 patients, whose liver were transplanted for HCC and were suspected of disease relapse based on biochemical analysis or SOC follow-up imaging, and carried out PET/MRI with diffusion-weighted imaging sequences on them. All patients underwent SOC imaging within the 2 months prior to the PET/MRI examination and had follow-up data for at least 12 months after. Reference standards were histopathology, clinical and imaging follow-up data.

RESULTS

Sensitivity, specificity, positive predictive value, negative predictive value and accuracy for PET/MRI were 100, 94, 91, 100 and 96%, whereas for SOC imaging were 80, 69, 61, 85 and 73%. The accuracy of PET/MRI was higher with respect to SOC imaging, although not significantly.

CONCLUSIONS

PET/MRI is useful for oncological surveillance of patients who have undergone liver transplantation for HCC, particularly in cases of allergy to contrast media, renal failure or persistently elevated alpha-fetoprotein levels, and with no identification of metastatic/relapsing foci at standard-of-care imaging.

Clinical advances in PET-MRI for breast cancer

Imaging is paramount for the early detection and clinical staging of breast cancer, as well as to inform management decisions and direct therapy. PET-MRI is a quantitative hybrid imaging technology that combines metabolic and functional PET data with anatomical detail and functional perfusion information from MRI. The clinical applicability of PET-MRI for breast cancer is an active area of research. In this Review, we discuss the rationale and summarise the clinical evidence for the use of PET-MRI in the diagnosis, staging, prognosis, tumour phenotyping, and assessment of treatment response in breast cancer. The continued development and approval of targeted radiopharmaceuticals, together with radiomics and automated analysis tools, will further expand the opportunity for PET-MRI to provide added value for breast cancer imaging and patient care.

Clinical Use of PET/MR in Oncology: An Update

The combination of PET and MRI is one of the recent advances of hybrid imaging. Yet to date, the adoption rate of PET/MRI systems has been rather slow. This seems to be partially caused by the high costs of PET/MRI systems and the need to verify an incremental benefit over PET/CT or sequential PET/CT and MRI. In analogy to PET/CT, the MRI part of PET/MRI was primarily used for anatomical imaging. Though this can be advantageous, for example in diseases where the superior soft tissue contrast of MRI is highly appreciated, the sole use of MRI for anatomical orientation lessens the potential of PET/MRI. Consequently, more recent studies focused on its multiparametric potential and employed diffusion weighted sequences and other functional imaging sequences in PET/MRI. This integration puts the focus on a more wholesome approach to PET/MR imaging, in terms of releasing its full potential for local primary staging based on multiparametric imaging and an included one-stop shop approach for whole-body staging. This approach as well as the implementation of computational analysis, in terms of radiomics analysis, has been shown valuable in several oncological diseases, as will be discussed in this review article.

The Value of 18F-FDG PET/CT and Abdominal PET/MRI as a One-Stop Protocol in Patients With Potentially Resectable Colorectal Liver Metastases

Purpose

The aim of this study was to evaluate the clinical value of simultaneous positron emission tomography/computed tomography (PET/CT) and abdominal positron emission tomography/magnet resonance imaging (PET/MRI) in the detection of liver metastases and extrahepatic disease (EHD) in patients with potentially resectable colorectal liver metastases (CLM).

Methods

Fifty-six patients with CLM underwent conventional imaging (chest and abdomen CT, liver contrast-enhanced CT or MRI) and PET imaging [fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) PET/CT and subsequent liver PET/MRI] for staging or restaging. Diagnostic ability of PET imaging was compared with conventional imaging. Abnormal findings were correlated with follow-up imaging and/or histology. The influence of the PET imaging findings was categorized for each patient in relation to operability and other significant findings. The clinical management included three modalities (surgery for resectable CLM, unresectable CLM with conversion treatment, and systemic therapy). The clinical impact of the imaging modality was analyzed. The operative histopathological analysis and/or imaging follow-up were performed as the standard of reference.

Results

This study enrolled a total of 56 patients (median age 60 years, 62.5% were male, 36 with colon cancer and 20 with rectal cancer). For EHD detection, PET/CT detected more EHD than conventional imaging (60.7% vs. 46.4%). PET/CT had different findings in 19 (33.9%) patients, including downstaging in 4 (7.1%) patients and upstaging in 15 (26.8%) patients. For liver lesion detection, PET/MRI showed comparable detection ability with CE-MRI and CE-CT (99.5%, 99.4%, and 86.5%, respectively) based on lesion analysis, much higher than PET/CT (47.5%). PET imaging had a major impact in 10/56 (17.9%) patients (4 from unresectable to resectable, 6 from resectable to unresectable) and a minor impact in 4/56 (7.1%) patients for changing the surgery extent. The therapeutic strategies had been altered in a total of 14/56 patients (25%) after PET/CT and PET/MRI scans.

Conclusion

The results of this study indicate that simultaneous ¹⁸F-FDG PET/CT and abdominal PET/MRI scans can provide accurate information regarding CLM status and EHD, and can affect the management of 25% of the patients by changing the therapeutic strategies determined by conventional imaging. This new modality may serve as a new one-stop method in patients with potentially resectable CLM.

Prospective comparison of CT and 18F-FDG PET/MRI in N and M staging of primary breast cancer patients: Initial results

Objectives

To compare the diagnostic accuracy of contrast-enhanced thoraco-abdominal computed tomography and whole-body ¹⁸F-FDG PET/MRI in N and M staging in newly diagnosed, histopathological proven breast cancer.

Material and methods

A total of 80 consecutive women with newly diagnosed and histopathologically confirmed breast cancer were enrolled in this prospective study. Following inclusion criteria had to be fulfilled: (1) newly diagnosed, treatment-naive T2-tumor or higher T-stage or (2) newly diagnosed, treatment-naive triple-negative tumor of every size or (3) newly diagnosed, treatment-naive tumor with molecular high risk (T1c, Ki67 >14%, HER2neu over-expression, G3). All patients underwent a thoraco-abdominal ceCT and a whole-body ¹⁸F-FDG PET/MRI. All datasets were evaluated by two experienced radiologists in hybrid imaging regarding suspect lesion count, localization, categorization and diagnostic confidence. Images were interpreted in random order with a reading gap of at least 4 weeks to avoid recognition bias. Histopathological results as well as follow-up imaging served as reference standard. Differences in staging accuracy were assessed using Mc Nemars chi² test.

Results

CT rated the N stage correctly in 64 of 80 (80%, 95% CI:70.0–87.3) patients with a sensitivity of 61.5% (CI:45.9–75.1), a specificity of 97.6% (CI:87.4–99.6), a PPV of 96% (CI:80.5–99.3), and a NPV of 72.7% (CI:59.8–82.7). Compared to this, ¹⁸F-FDG PET/MRI determined the N stage correctly in 71 of 80 (88.75%, CI:80.0–94.0) patients with a sensitivity of 82.1% (CI:67.3–91.0), a specificity of 95.1% (CI:83.9–98.7), a PPV of 94.1% (CI:80.9–98.4) and a NPV of 84.8% (CI:71.8–92.4). Differences in sensitivities were statistically significant (difference 20.6%, CI:-0.02–40.9; p = 0.008). Distant metastases were present in 7/80 patients (8.75%). ¹⁸ F-FDG PET/MRI detected all of the histopathological proven metastases without any false-positive findings, while 3 patients with bone metastases were missed in CT (sensitivity 57.1%, specificity 95.9%). Additionally, CT presented false-positive findings in 3 patients.

Conclusion

¹⁸F-FDG PET/MRI has a high diagnostic potential and outperforms CT in assessing the N and M stage in patients with primary breast cancer.

Diagnostic Value of Delayed PET/MR in Liver Metastasis in Comparison With PET/CT

Objectives

The aim of this study was to evaluate the value of a delayed positron emission tomography/magnetic resonance (PET/MR) scan relative to a single positron emission tomography/computed tomography (PET/CT) scan for liver metastasis detection.

Methods

In this study, 70 patients with solid malignancies and suspicious liver lesions undergoing 2-deoxy-2-[¹⁸F]fluoro-D-glucose [(¹⁸F)FDG] PET/CT and subsequent delayed liver PET/MR scans were analyzed. The histopathological analysis and/or imaging follow-up were performed as the standard of reference. Lesion maximum standardized uptake value (SUVmax), diameter, and tumor to nontumor ratio (T/N) were measured. Lesion detection sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for both examinations.

Results

(1) The standard of reference revealed 208 liver lesions in 70 patients (metastasis in 56 patients with 196 lesions; benign in 14 patients with 12 lesions). Compared with PET/CT, PET/MR had higher accuracy (98.6% vs. 78.6%), sensitivity (98.2% vs. 76.8%), and specificity (100.0% vs. 85.7%) (2). The therapeutic strategies of 29 patients (41.4%) needed reconsideration after the additional PET/MR, including new metastases detected (13/70), new affected lobes identified (14/70), and false-positive corrected (2/70) (3). PET/MR detected significantly more metastases than PET/CT did, especially with small lesions. The SUVmax of the same lesion correlated well between the two acquisitions, while the delayed PET showed a higher T/N ratio.

Conclusions

In liver metastasis detection, the diagnostic value of the delayed PET/MR is validated to be superior to that of PET/CT, which may aid the clinical decision-making.

Clinical Applications of PET/MR Imaging

PET/MR imaging is in routine clinical use and is at least as effective as PET/CT for oncologic and neurologic studies with advantages with certain PET radiopharmaceuticals and applications. In addition, whole body PET/MR imaging substantially reduces radiation dosages compared with PET/CT which is particularly relevant to pediatric and young adult population. For cancer imaging, assessment of hepatic, pelvic, and soft-tissue malignancies may benefit from PET/MR imaging. For neurologic imaging, volumetric brain MR imaging can detect regional volume loss relevant to cognitive impairment and epilepsy. In addition, the single-bed position acquisition enables dynamic brain PET imaging without extending the total study length which has the potential to enhance the diagnostic information from PET.

PET Imaging for Breast Cancer

Imaging plays an integral role in the clinical care of patients with breast cancer. This review article focuses on the use of PET imaging for breast cancer, highlighting the clinical indications and limitations of 2-deoxy-2-[¹⁸F]fluoro-d-glucose (FDG) PET/CT, the potential use of PET/MRI, and 16α-[¹⁸F]fluoroestradiol (FES), a newly approved radiopharmaceutical for estrogen receptor imaging.

Impact of 18F-FDG PET/MR based tumor delineation in radiotherapy planning for cholangiocarcinoma

PURPOSE

Radiation therapy (RT) is an effective treatment for unresectable cholangiocarcinoma (CC). Accurate tumor volume delineation is critical in achieving high rates of local control while minimizing treatment-related toxicity. This study compares ¹⁸F-FDG PET/MR to MR and CT for target volume delineation for RT planning.

METHODS

We retrospectively included 22 patients with newly diagnosed unresectable primary CC who underwent ¹⁸F-FDG PET/MR for initial staging. Gross tumor volume (GTV) of the primary mass (GTV_M) and lymph nodes (GTV_LN) were contoured on CT images, MR images, and PET/MR fused images and compared among modalities. The dice similarity coefficient (DSC) was calculated to assess spatial coverage between different modalities.

RESULTS

GTV _M ^PET/MR (median: 94 ml, range 16-655 ml) was significantly greater than GTV _M ^MR (69 ml, 11-635 ml) (p = 0.0001) and GTV _M ^CT (96 ml, 4-564 ml) (p = 0.035). There was no significant difference between GTV _M ^CT and GTV _M ^MR (p = 0.078). Subgroup analysis of intrahepatic and extrahepatic tumors showed that the median GTV _M ^PET/MR was significantly greater than GTV _M ^MR in both groups (117.5 ml, 22-655 ml vs. 102.5 ml, 22-635 ml, p = 0.004 and 37 ml, 16-303 ml vs. 34 ml, 11-207 ml, p = 0.042, respectively). The GTV _LN ^PET/MR (8.5 ml, 1-27 ml) was significantly higher than GTV _LN ^CT (5 ml, 4-16 ml) (p = 0.026). GTV^PET/MR had the highest similarity to the GTV^MR, i.e., DSC^PET/MR-MR (0.82, 0.25-1.00), compared to DSC ^PET/MR-CT of 0.58 (0.22-0.87) and DSC^MR-CT of 0.58 (0.03-0.83).

CONCLUSION

¹⁸F-FDG PET/MR-based CC delineation yields greater GTVs and detected a higher number of positive lymph nodes compared to CT or MR, potentially improving RT planning by reducing the risk of geographic misses.

PET/MRI for Staging the Axilla in Breast Cancer: Current Evidence and the Rationale for SNB vs. PET/MRI Trials

Simple Summary

PET/MRI is a relatively new, hybrid imaging tool that allows practitioners to obtain both a local and systemic staging in breast cancer patients in a single exam. To date, the available evidence is not sufficient to determine the role of PET/MRI in breast cancer management. The aims of this paper are to provide an overview of the current literature on PET/MRI in breast cancer, and to illustrate two ongoing trials aimed at defining the eventual role of PET/MRI in axillary staging in two different settings: patients with early breast cancer and patients with positive axillary nodes that are candidates for primary systemic therapy. In both cases, findings from PET/MRI will be compared with the final pathology and could be helpful to better tailor axillary surgery in the future.

Abstract

Axillary surgery in breast cancer (BC) is no longer a therapeutic procedure but has become a purely staging procedure. The progressive improvement in imaging techniques has paved the way to the hypothesis that prognostic information on nodal status deriving from surgery could be obtained with an accurate diagnostic exam. Positron emission tomography/magnetic resonance imaging (PET/MRI) is a relatively new imaging tool and its role in breast cancer patients is still under investigation. We reviewed the available literature on PET/MRI in BC patients. This overview showed that PET/MRI yields a high diagnostic performance for the primary tumor and distant lesions of liver, brain and bone. In particular, the results of PET/MRI in staging the axilla are promising. This provided the rationale for two prospective comparative trials between axillary surgery and PET/MRI that could lead to a further de-escalation of surgical treatment of BC. • SNB vs. PET/MRI 1 trial compares PET/MRI and axillary surgery in staging the axilla of BC patients undergoing primary systemic therapy (PST). • SNB vs. PET/MRI 2 trial compares PET/MRI and sentinel node biopsy (SNB) in staging the axilla of early BC patients who are candidates for upfront surgery. Finally, these ongoing studies will help clarify the role of PET/MRI in BC and establish whether it represents a useful diagnostic tool that could guide, or ideally replace, axillary surgery in the future.

Imaging and its Impact on Defining the Oligometastatic State

Successful treatment of oligometastatic disease (OMD) is facilitated through timely detection and localization of disease, both at the time of initial diagnosis (synchronous OMD) and following the initial therapy (metachronous OMD). Hence, imaging plays an indispensable role in management of patients with OMD. However, the challenges and complexities of OMD management are also reflected in the imaging of this entity. While innovations and advances in imaging technology have made a tremendous impact in disease detection and management, there remain substantial and unaddressed challenges for earlier and more accurate establishment of OMD state. This review will provide an overview of the available imaging modalities and their inherent strengths and weaknesses, with a focus on their role and potential in detection and evaluation of OMD in different organ systems. Furthermore, we will review the role of imaging in evaluation of OMD for malignancies of various primary organs, such as the lung, prostate, colon/rectum, breast, kidney, as well as neuroendocrine tumors and gynecologic malignancies. We aim to provide a practical overview about the utilization of imaging for clinicians who play a role in the care of those with, or at risk for OMD.

An international expert opinion statement on the utility of PET/MR for imaging of skeletal metastases

BACKGROUND

MR is an important imaging modality for evaluating musculoskeletal malignancies owing to its high soft tissue contrast and its ability to acquire multiparametric information. PET provides quantitative molecular and physiologic information and is a critical tool in the diagnosis and staging of several malignancies. PET/MR, which can take advantage of its constituent modalities, is uniquely suited for evaluating skeletal metastases. We reviewed the current evidence of PET/MR in assessing for skeletal metastases and provided recommendations for its use.

METHODS

We searched for the peer reviewed literature related to the usage of PET/MR in the settings of osseous metastases. In addition, expert opinions, practices, and protocols of major research institutions performing research on PET/MR of skeletal metastases were considered.

RESULTS

Peer-reviewed published literature was included. Nuclear medicine and radiology experts, including those from 13 major PET/MR centers, shared the gained expertise on PET/MR use for evaluating skeletal metastases and contributed to a consensus expert opinion statement. [18F]-FDG and non [18F]-FDG PET/MR may provide key advantages over PET/CT in the evaluation for osseous metastases in several primary malignancies.

CONCLUSION

PET/MR should be considered for staging of malignancies where there is a high likelihood of osseous metastatic disease based on the characteristics of the primary malignancy, hight clinical suspicious and in case, where the presence of osseous metastases will have an impact on patient management. Appropriate choice of tumor-specific radiopharmaceuticals, as well as stringent adherence to PET and MR protocols, should be employed.

Breast implant associated anaplastic large cell lymphoma (BIA-ALCL): a challenging cytological diagnosis with hybrid PET/MRI staging and follow-up

We report a case of a 55-year-old woman with left breast cosmetic augmentation performed 5 years earlier, showing at ultrasound a left small amount of peri-implant effusion suspicious for an anaplastic large cell lymphoma localization. The final diagnosis was obtained by cytology using a small amount of fluid (6 ml). Subsequently, hybrid 18F-FDG PET/MRI was used for pre-operative staging and follow-up. An appropriate management of BIA-ALCL could be obtained even in cases of a small amount of peri-implant effusion, using a comprehensive approach of clinical and imaging evaluation, including PET/MRI as useful and innovative staging imaging technique.

[18F]FDG PET/MRI in rectal cancer

We conducted a systematic literature review on the use of [18F]FDG PET/MRI for staging/restaging rectal cancer patients with PubMed, Scopus, and Web of Science, based on the PRISMA criteria. Three authors screened all titles and abstracts and examined the full texts of all the identified relevant articles. Studies containing aggregated or duplicated data, review articles, case reports, editorials, and letters were excluded. Ten reports met the inclusion criteria. Four studies examined T staging and one focused on local recurrences after surgery; the reported sensitivity (94-100%), specificity (73-94%), and accuracy (92-100%) varied only slightly from one study to another. The sensitivity, specificity, and accuracy of [18F]FDG PET/MRI for N staging were 90-93%, 92-94%, and 42-92%. [18F]FDG PET/MRI detected malignant nodes better than MRI, resulting in treatment change. For M staging, [18F]FDG PET/MRI outperformed [18F]FDG PET/CT and CT in detecting liver metastases, whereas it performed worse for lung metastases. The results of this review suggest that [18F]FDG PET/MRI should be used for rectal cancer restaging after chemoradiotherapy and to select patients for rectum-sparing approaches thanks to its accuracy in T and N staging. For M staging, it should be associated at least with a chest CT scan to rule out lung metastases.

Value of 18F-FDG PET/CT in patients with hepatic metastatic carcinoma of unknown primary

PURPOSE

This retrospective study aimed to investigate the clinical value of -deoxy-2-(F)-fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) in detecting primary lesions of hepatic metastases.

METHODS

A total of 124 patients with hepatic metastatic carcinoma of unknown primary underwent whole body F-FDG PET/CT imaging. According to the final diagnoses for both primary sites and hepatic metastases that were confirmed either histopathologically or by clinical follow up, all patients were divided into 4 groups: a true positive group (TP, 95 cases), a false positive group (FP, 9), a true negative group (TN, 8) and a false negative group (FN, 12).

RESULTS

The TP rate of primary lesions, detected by F-FDG PET/CT, was 76.61%, the FP rate 7.26%, the TN rate 6.45% and the FN rate 9.68%. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of F-FDG PET/CT in the detection of primary tumors were 88.78%, 52.94%, 91.35%, 40%, and 83.06%, respectively. Accurate diagnosis groups (TP, TN) showed a significantly higher SUVmax (standard uptake maximum value) level than that in error diagnosis groups (FP, FN). The SUVmax between hepatic metastases and primary lesions had a positive correlation. The primary tumor sites of hepatic metastases were mainly located in the gastrointestinal organs and the lungs.

CONCLUSIONS

Whole body F-FDG PET/CT imaging was sensitive for detecting primary sites/lesions with hepatic metastatases of unknown primary, especially when the SUVmax of hepatic metastases were greater than 4.7.

Prospective evaluation of whole-body MRI and 18F-FDG PET/MRI in N and M staging of primary breast cancer patients

OBJECTIVES

To evaluate and compare the diagnostic potential of whole-body MRI and whole-body 18F-FDG PET/MRI for N and M staging in newly diagnosed, histopathologically proven breast cancer.

MATERIAL AND METHODS

A total of 104 patients (age 53.4 ± 12.5) with newly diagnosed, histopathologically proven breast cancer were enrolled in this study prospectively. All patients underwent a whole-body 18F-FDG PET/MRI. MRI and 18F-FDG PET/MRI datasets were evaluated separately regarding lesion count, lesion localization, and lesion characterization (malignant/benign) as well as the diagnostic confidence (5-point ordinal scale, 1-5). The N and M stages were assessed according to the eighth edition of the American Joint Committee on Cancer staging manual in MRI datasets alone and in 18F-FDG PET/MRI datasets, respectively. In the majority of lesions histopathology served as the reference standard. The remaining lesions were followed-up by imaging and clinical examination. Separately for nodal-positive and nodal-negative women, a McNemar chi2 test was performed to compare sensitivity and specificity of the N and M stages between 18F-FDG PET/MRI and MRI. Differences in diagnostic confidence scores were assessed by Wilcoxon signed rank test.

RESULTS

MRI determined the N stage correctly in 78 of 104 (75%) patients with a sensitivity of 62.3% (95% CI: 0.48-0.75), a specificity of 88.2% (95% CI: 0.76-0.96), a PPV (positive predictive value) of 84.6% % (95% CI: 69.5-0.94), and a NPV (negative predictive value) of 69.2% (95% CI: 0.57-0.8). Corresponding results for 18F-FDG PET/MRI were 87/104 (83.7%), 75.5% (95% CI: 0.62-0.86), 92.2% (0.81-0.98), 90% (0.78-0.97), and 78.3% (0.66-0.88), showing a significantly better sensitivity of 18F-FDG PET/MRI determining malignant lymph nodes (p = 0.008). The M stage was identified correctly in MRI and 18F-FDG PET/MRI in 100 of 104 patients (96.2%). Both modalities correctly staged all 7 patients with distant metastases, leading to false-positive findings in 4 patients in each modality (3.8%). In a lesion-based analysis, 18F-FDG PET/MRI showed a significantly better performance in correctly determining malignant lesions (85.8% vs. 67.1%, difference 18.7% (95% CI: 0.13-0.26), p < 0.0001) and offered a superior diagnostic confidence compared with MRI alone (4.1 ± 0.7 vs. 3.4 ± 0.7, p < 0.0001).

CONCLUSION

18F-FDG PET/MRI has a better diagnostic accuracy for N staging in primary breast cancer patients and provides a significantly higher diagnostic confidence in lesion characterization than MRI alone. But both modalities bear the risk to overestimate the M stage.

Diagnostic performance of PET/computed tomography versus PET/MRI and diffusion-weighted imaging in the N- and M-staging of breast cancer patients

OBJECTIVE

To provide a systematic review regarding the diagnostic performance of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) and diffusion-weighted imaging (DWI) compared to 18F-FDG PET/computed tomography (CT) focused on nodal and distant staging in breast cancer patients.

METHODS

The PubMed and Embase databases were searched for relevant publications until April 2020. Two independent reviewers searched for eligible articles based on predefined in- and exclusion criteria, assessed quality and extracted data.

RESULTS

Eleven eligible studies were selected from 561 publications identified by the search. In seven studies, PET/CT was compared with PET/MRI, and in five, PET/CT with DWI. Significantly higher sensitivity for PET/MRI compared to PET/CT in a lesion-based analysis was reported for all lesions together (77% versus 89%) in one study, osseous metastases (69-99% versus 92-98%) in two studies and hepatic metastases (70-75% versus 80-100%) in one study. Moreover, PET/MRI revealed a significantly higher amount of osseous metastases (90 versus 141) than PET/CT. PET/CT is associated with a statistically higher specificity than PET/MRI in the lesion detection of all lesions together (98% versus 96%) and of osseous metastases (100% versus 95%), both in one study. None of the reviewed studies reported significant differences between PET/CT and DWI for any of the evaluated sites. There is a trend toward higher specificity for PET/CT.

CONCLUSION

In general, there is a trend toward higher sensitivity and lower specificity of PET/MRI when compared to PET/CT. Results on the diagnostic performance of DWI are conflicting. Rather than evaluating it separate, it seems to have complementary value when combined with other MR sequences.

Progress and Future Trends in PET/CT and PET/MRI Molecular Imaging Approaches for Breast Cancer

Breast cancer is a major disease with high morbidity and mortality in women worldwide. Increased use of imaging biomarkers has been shown to add more information with clinical utility in the detection and evaluation of breast cancer. To date, numerous studies related to PET-based imaging in breast cancer have been published. Here, we review available studies on the clinical utility of different PET-based molecular imaging methods in breast cancer diagnosis, staging, distant-metastasis detection, therapeutic and prognostic prediction, and evaluation of therapeutic responses. For primary breast cancer, PET/MRI performed similarly to MRI but better than PET/CT. PET/CT and PET/MRI both have higher sensitivity than MRI in the detection of axillary and extra-axillary nodal metastases. For distant metastases, PET/CT has better performance in the detection of lung metastasis, while PET/MRI performs better in the liver and bone. Additionally, PET/CT is superior in terms of monitoring local recurrence. The progress in novel radiotracers and PET radiomics presents opportunities to reclassify tumors by combining their fine anatomical features with molecular characteristics and develop a beneficial pathway from bench to bedside to predict the treatment response and prognosis of breast cancer. However, further investigation is still needed before application of these modalities in clinical practice. In conclusion, PET-based imaging is not suitable for early-stage breast cancer, but it adds value in identifying regional nodal disease and distant metastases as an adjuvant to standard diagnostic imaging. Recent advances in imaging techniques would further widen the comprehensive and convergent applications of PET approaches in the clinical management of breast cancer.