Breast Cancer NM Flashcards
Breast cancer T
Breast cancer N
Breast cancer M
Bone
Lung
Brain (ER-, HR-)
Liver
Leptomeninges, brain, gyn, GIT (ILC)
Luminal A 50-55%
ER+
PR+
HER2-
Ki67-
Best prognosis
Hormone therapy - - aromatase inhibitor, tamoxifen
Luminal B 15%
ER+
PR+
HER2 +-(30%)
Ki67+
Hormone therapy
HER2 15%
ER-
PR-
HER2+
Trastuzumab, pertuzumab
Cardiotoxic - - MUGA
Basal-like type 10-20%
Triple negative
Cytotoxic therapy
ER+
75% of cases
Breast cancer US
More sensitive than mammography in IDC
US vs MRI to assess largest diameter
LN MTS - - focal cortical thickening >3mm, round (not reni form), no fatty hilum
Breast cancer MRI
High risk screening
Extent of disease
Recurrence vs scar
Perform in days 7-10 of cycle
Not accurate to assess cortical thickening of LN
Breast cancer FDG
No in stage I, II or operable III - - false positive
Less sensitive for <1 cm, ILC, grade 1, well diff
Stage III+, locally advanced, inflammatory, recurrent, metastatic - - not replace SLNB - - limited in LN <8 mm
IDC>ILC
Early cancer - - sensitivity to detect axillary adenopathy 20-50%
Breast cancer FDG
Response to treatment
Complete response - - complete resolution of lesions
Partial response - - reduction >15% SUV after 1 cycle, >25% after >2 cycles
PERCIST - - partial response - - reduction >30% SUL (SUV for lean body mass)
Complete response - - uptake of target lesions <liver
Breast cancer F-FLT (thymidine)
Good correlation with Ki67, but signal <FDG - - false negative
Phosphorylated by thymidine kinase
Breast cancer C-Methionine (amino acid)
Correlated with cells in S phase
T1/2 20 min - - cyclotron
F-fluciclovine
F-FACBC
Also prostate cancer
O15-labeled water
T1/2 2 min - - cyclotron
Combi with FDG
Tumor blood flow
F-FES
F-fluoroestradiol
ER expression
Patients who can not be biopsied
Sensitivity 70-100%, specificity 80-100%
F-FDHT
F-fluorodihydrotestosterone
AR expression
F-FFNP
PR specific tracer
Efficacy of antiestrogen therapy
In111-trastuzumab SPECT
Replaced by
Zn89 - - PET - - T1/2 78.4h - - cross BBB
Cu64 - - PET - - T1/2 12.7h - - less radiation exposure
Breast cancer Bone scan
Stage I-IIIC - - CT and bone scan
Stage IV - - 70% bone MTS - - CT, bone scan, MRI
FDG - - optional for high risk
Bone scan sensitivity 88%
Response to treatment - - 6 months
Lytic bone MTS with soft tissue mass >10 mm are measurable
Scintimammography
MBI = molecular breast imaging
Modern BSGI = breast specific gamma imaging
Sestamibi 20-30 mCi - - planar 5-10 min after IV - - lateral and oblique prone with hanging breasts - - anterior, oblique and SPECT supine
Radiation dose 0.07 mSv vs 0.44 mSv mammography
MIBI interpretation
Accumulates within mitochondria
P-glycoprotein - - multidrug resistant gene - - efficacy of anti cancer drug
Non specific - - false positive - - surgery, fibroadenoma, atypical hyperplasia
Small non palpable - - early disease - - scan negative - - observation
>2 cm - - 100% sensitivity
MIBI indication
Nipple discharge
Lesions BIRADS-3
Identified lesions
Multiple masses
Architectural distortion
Not possible MRI
MIBI and diagnosed cancer
Extent
Multicentric vs multifocal vs bilateral
Response to neoadjuvant chemo
Axillary MTS
Treatment
Adjuvant systemic therapy if LN>1 cm
Postmastectomy radio
Contra to breast conserving therapy
Positive resection margins
Multicentric disease (>2 tumors in separate quadrants)
Prior radio
Pregnancy
SLNB location
Majority to subareolar Sappey plexus
3% internal mammary chain
SLNB injection
Intratumoral - - high activity up to 10 mCi, large volume up to 4 ml - - shine through
Peritumoral (deep) - - 2-4 aliquotes on each side 125-250 microCi 0.5-1.0 ml = gold standard - - 20-30% internal mammary
Intra/subdermal - - 0.1 ml - - small wheal
Periareolar (superficial) - - 2-4 injections 0.1 ml
SLNB indication and Contra
Indication - T1, T2, DCIS>2.5 cm (+mastectomy), before neoadjuvant, male, old, obese without proven axillary LN MTS!!
Offer - multicentric, previous surgery or neoadjuvant
Contra - T3, T4, inflammatory, DCIS without mastectomy, pregnant
SLNB interpretation
No SLN - - old, obese, tumor not in upper outer quadrant - - no ALND, but if not found during surgery - - maybe ALND
1-2 SLN - - no ALND - - breast conserving surgery + RADIO of whole breast
Positive - - mastectomy + ALND
ROLL
Radioguided occult lesion localisation
Tc-MAA 2-15 MBq size 10-150 microm
Intratumoral
Add contrast to radioactive preparation - - mammogram to check correct position
Early stage non palpable breast cancer during breast conserving surgery
ROLL with seeds
Similar to Brachytherapy in prostate cancer
4.5*0.8 mm titanium capsule with 1-10 MBq I125
T1/2 59.4 dayst
Low energy gamma 27 keV
In center of non palpable breast lesion few days before surgery
Excision guided by gamma probe
SNOLL
Sentinel node and occult lesion localisation
TC-MAA intratumoral for ROLL + Tc-nanocolloid subdermal/intratumoral for SLNB
Only a minor fraction migrated through lymphatic channels - - most retained at injection site
If use Seeds for ROLL - - energy window of gamma probe between 27 keV of I125 and 140 keV of Tc - - discriminate gamma ray emission
MIBI scintimammography
PEM with FDG
Positron emission mammography
MTS
MTS
Bone fracture
Treatment according to N status
N1 - - surgery + chemo/hormone
N2 - - additional radio
N3 - - neoadjuvant chemo
Negative PET post chemo
25% recurrence
Postsurgical seroma
Breast cancer risk
Nullipara or after 30
Breastfeeding >1 year lower risk
Early menarche, late menopause
HRT
Alco
Previous radio before 30
