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      Staging the axilla in breast cancer patients with 18F-FDG PET: how small are the metastases that we can detect with new generation clinical PET systems?

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          Abstract

          Purpose

          Point spread function (PSF) reconstruction improves spatial resolution throughout the entire field of view of a PET system and can detect smaller metastatic deposits than conventional algorithms such as OSEM. We assessed the impact of PSF reconstruction on quantitative values and diagnostic accuracy for axillary staging of breast cancer patients, compared with an OSEM reconstruction, with emphasis on the size of nodal metastases.

          Methods

          This was a prospective study in a single referral centre in which 50 patients underwent an 18F-FDG PET examination before axillary lymph node dissection. PET data were reconstructed with an OSEM algorithm and PSF reconstruction, analysed blindly and validated by a pathologist who measured the largest nodal metastasis per axilla. This size was used to evaluate PET diagnostic performance.

          Results

          On pathology, 34 patients (68 %) had nodal involvement. Overall, the median size of the largest nodal metastasis per axilla was 7 mm (range 0.5 – 40 mm). PSF reconstruction detected more involved nodes than OSEM reconstruction ( p = 0.003). The mean PSF to OSEM SUV max ratio was 1.66 (95 % CI 1.01 – 2.32). The sensitivities of PSF and OSEM reconstructions were, respectively, 96 % and 92 % in patients with a largest nodal metastasis of >7 mm, 60 % and 40 % in patients with a largest nodal metastasis of ≤7 mm, and 92 % and 69 % in patients with a primary tumour ≤30 mm. Biggerstaff graphical comparison showed that globally PSF reconstruction was superior to OSEM reconstruction. The median sizes of the largest nodal metastasis in patients with nodal involvement not detected by either PSF or OSEM reconstruction, detected by PSF but not by OSEM reconstruction and detected by both reconstructions were 3, 6 and 16 mm ( p = 0.0064) respectively. In patients with nodal involvement detected by PSF reconstruction but not by OSEM reconstruction, the smallest detectable metastasis was 1.8 mm.

          Conclusion

          As a result of better activity recovery, PET with PSF reconstruction performed better than PET with OSEM reconstruction in detecting nodal metastases ≤7 mm. However, its sensitivity is still insufficient for it to replace surgical approaches for axillary staging. PET with PSF reconstruction could be used to perform sentinel node biopsy more safely in patients with a primary tumour ≤30 mm and with unremarkable PET results in the axilla.

          Electronic supplementary material

          The online version of this article (doi:10.1007/s00259-014-2689-7) contains supplementary material, which is available to authorized users.

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          Most cited references29

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          FDG PET and PET/CT: EANM procedure guidelines for tumour PET imaging: version 1.0

          The aim of this guideline is to provide a minimum standard for the acquisition and interpretation of PET and PET/CT scans with [18F]-fluorodeoxyglucose (FDG). This guideline will therefore address general information about [18F]-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) and is provided to help the physician and physicist to assist to carrying out, interpret, and document quantitative FDG PET/CT examinations, but will concentrate on the optimisation of diagnostic quality and quantitative information.
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            Refining clinical diagnosis with likelihood ratios.

            Likelihood ratios can refine clinical diagnosis on the basis of signs and symptoms; however, they are underused for patients' care. A likelihood ratio is the percentage of ill people with a given test result divided by the percentage of well individuals with the same result. Ideally, abnormal test results should be much more typical in ill individuals than in those who are well (high likelihood ratio) and normal test results should be most frequent in well people than in sick people (low likelihood ratio). Likelihood ratios near unity have little effect on decision-making; by contrast, high or low ratios can greatly shift the clinician's estimate of the probability of disease. Likelihood ratios can be calculated not only for dichotomous (positive or negative) tests but also for tests with multiple levels of results, such as creatine kinase or ventilation-perfusion scans. When combined with an accurate clinical diagnosis, likelihood ratios from ancillary tests improve diagnostic accuracy in a synergistic manner.
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              Comparing diagnostic tests: a simple graphic using likelihood ratios.

              The diagnostic abilities of two or more diagnostic tests are traditionally compared by their respective sensitivities and specificities, either separately or using a summary of them such as Youden's index. Several authors have argued that the likelihood ratios provide a more appropriate, if in practice a less intuitive, comparison. We present a simple graphic which incorporates all these measures and admits easily interpreted comparison of two or more diagnostic tests. We show, using likelihood ratios and this graphic, that a test can be superior to a competitor in terms of predictive values while having either sensitivity or specificity smaller. A decision theoretic basis for the interpretation of the graph is given by relating it to the tent graph of Hilden and Glasziou (Statistics in Medicine, 1996). Finally, a brief example comparing two serodiagnostic tests for Lyme disease is presented. Published in 2000 by John Wiley & Sons, Ltd.
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                Author and article information

                Contributors
                +33-231455268 , +33-231455101 , n.aide@baclesse.unicancer.fr
                Journal
                Eur J Nucl Med Mol Imaging
                Eur. J. Nucl. Med. Mol. Imaging
                European Journal of Nuclear Medicine and Molecular Imaging
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                1619-7070
                1619-7089
                22 February 2014
                22 February 2014
                2014
                : 41
                : 1103-1112
                Affiliations
                [ ]Nuclear Medicine Department, François Baclesse Cancer Centre, Avenue Général Harris, 14076 Cedex 5, Caen France
                [ ]Pathology Department, François Baclesse Cancer Centre, Caen, France
                [ ]Breast Cancer Unit, François Baclesse Cancer Centre, Caen, France
                [ ]Biostatistics and Clinical Research unit, François Baclesse Cancer Centre, Caen, France
                [ ]Radiation Oncology Department, François Baclesse Cancer Centre, Caen, France
                [ ]Medical Physics Department, University Hospital, Caen, France
                [ ]Surgical Oncology, François Baclesse Cancer Centre, Caen, France
                [ ]Normandie Université, Caen, France
                Article
                2689
                10.1007/s00259-014-2689-7
                4006125
                24562642
                f21758ab-0337-4dea-82cf-e664e1190c30
                © The Author(s) 2014

                Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

                History
                : 17 September 2013
                : 2 January 2014
                Categories
                Original Article
                Custom metadata
                © Springer-Verlag Berlin Heidelberg 2014

                Radiology & Imaging
                pet/ct,breast cancer,axillary staging,fluorodeoxyglucose,psf reconstruction
                Radiology & Imaging
                pet/ct, breast cancer, axillary staging, fluorodeoxyglucose, psf reconstruction

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