Jean H. Lee

Between-Patient and Within-Patient (Site-to-Site) Variability in Estrogen Receptor Binding, Measured In Vivo by 18F-Fluoroestradiol PET

Heterogeneity of estrogen receptor (ER) expression may be an important predictor of breast cancer therapeutic response. 18F-fluoroestradiol PET produces in vivo quantitative measurements of regional estrogen binding in breast cancer tumors. We describe within-patient (site-to-site) and between-patient heterogeneity of lesions in patients scheduled to receive endocrine therapy. Methods: In 91 patients with a prior ER-positive biopsy, 505 lesions were analyzed for both 18F-fluoroestradiol and 18F-FDG uptake and the 18F-fluoroestradiol/18F-FDG uptake ratio. Standardized uptake values (SUVs) were recorded for up to 16 lesions per patient, of 1.5 cm or more and visible on 18F-FDG PET or conventional staging. Linear mixed-effects regression models examined associations between PET parameters and patient or lesion characteristics and estimated variance components. A reader study of SUV measurements for 9 scans further examined sources of within-patient variability. Results: Average 18F-fluoroestradiol uptake and 18F-fluoroestradiol/18F-FDG ratio varied greatly across these patients, despite a history of ER-positive disease: about 37% had low or absent 18F-fluoroestradiol uptake even with marked 18F-FDG uptake. 18F-fluoroestradiol SUV and 18F-fluoroestradiol/18F-FDG ratio measurements within patients with multiple lesions were clustered around the patients average value in most cases. Summarizing these findings, the intraclass correlation coefficient (proportion of total variation that is between-patient) was 0.60 (95% confidence interval, 0.50–0.69) for 18F-fluoroestradiol SUV and 0.65 (95% confidence interval, 0.56–0.73) for the 18F-fluoroestradiol/18F-FDG ratio. Some within-patient variation in PET measures (22%–44%) was attributable to interobserver variability as measured by the reader study. A subset of patients had mixed uptake, with widely disparate 18F-fluoroestradiol SUV or 18F-fluoroestradiol/18F-FDG ratio for lesions in the same scan. Conclusion: 18F-fluoroestradiol uptake and the 18F-fluoroestradiol/18F-FDG ratio varied greatly between patients but were usually consistent across lesions in the same scan. The average 18F-fluoroestradiol SUV and 18F-fluoroestradiol/18F-FDG ratio for a limited sample of lesions appear to provide a reasonable summary of synchronous ER expression for most patients. However, imaging the entire disease burden remains important to identify the subset of patients with mixed uptake, who may be at a critical point in their disease evolution.

The Role of Radiotracer Imaging in the Diagnosis and Management of Patients with Breast Cancer: Part 1—Overview, Detection, and Staging

Breast cancer is the most common non-skin type of cancer and the second leading cause of cancer mortality in women. Advances in diagnosis and treatment have led to declines in mortality, despite an increase in breast cancer incidence. An advancing array of both local and systemic therapy options has led to increasingly individualized treatment. Imaging plays a key role in detecting breast cancer and directing its therapy. This continuing education article, part 1 in a 2-part series, provides a comprehensive review of current and future radiotracer imaging methods applied to breast cancer, in the context of breast cancer management strategies and other nonnuclear imaging methods. Part 1 of the review provides an overview of clinical and biologic considerations in breast cancer and covers radionuclide imaging for detection and staging. Part 2 will cover radionuclide imaging of breast cancer response to therapy, other clinical indications for radionuclide breast cancer imaging, and future directions, including molecular imaging.

The Role of Radiotracer Imaging in the Diagnosis and Management of Patients with Breast Cancer: Part 2—Response to Therapy, Other Indications, and Future Directions

Breast cancer is the most common non-skin type of cancer and the second leading cause of cancer mortality in women. Advances in diagnosis and treatment have led to declines in mortality, despite an increase in breast cancer incidence. An advancing array of both local and systemic therapy options has led to increasingly individualized treatment. Imaging plays a key role in detecting breast cancer and directing its therapy. This continuing education article provides a comprehensive review of current and future radiotracer imaging methods applied to breast cancer, in the context of breast cancer management strategies and other nonnuclear imaging methods. Part 1 of the review provided an overview of clinical and biologic considerations in breast cancer and covered radionuclide imaging for detection and staging. Part 2 covers radionuclide imaging of breast cancer response to therapy, other clinical indications for radionuclide breast cancer imaging, and future directions, including molecular imaging.

Magnetic Resonance Imaging of Pelvic Floor Dysfunction

Pelvic floor dysfunction is largely a complex problem of multiparous and postmenopausal women and is associated with pelvic floor or organ descent. Physical examination can underestimate the extent of the dysfunction and misdiagnose the disorders. Functional magnetic resonance (MR) imaging is emerging as a promising tool to evaluate the dynamics of the pelvic floor and use for surgical triage and operative planning. This article reviews the anatomy and pathology of pelvic floor dysfunction, typical imaging findings, and the current role of functional MR imaging.

Radionuclide Methods for Breast Cancer Staging

Staging at initial presentation is one of the important prognostic factors for patients with breast cancer. Depending on the extent of disease spread, staging is divided into locoregional and distant or systemic. Locoregional staging includes axillary and internal mammary lymph node evaluation and distant or systemic staging includes evaluation of sites beyond the lymph node. Fluorodeoxyglucose-positron emission tomography (FDG-PET) is not sensitive to detect small metastasis in axillary lymph node. The current standard of axillary lymph node staging in early-stage breast cancer is therefore sentinel lymph node biopsy. Internal mammary lymph nodes are not commonly included in routine staging. In advanced-stage breast cancer, FDG-PET and PET/computed tomography (CT) are the modalities of choice to evaluate locoregional and distant metastasis. FDG-PET and PET/CT often detect occult metastasis, which is not visible on any other modalities including diagnostic CT scan. Detection of occult metastasis may potentially change in treatment options. This is particularly important in locally advanced breast cancer, which tends to develop early distant metastasis.

Imaging of Postpartum Complications: A Multimodality Review

OBJECTIVE The purpose of this article is to review common and uncommon complications of postpartum and posttermination patients and their imaging findings. A variety of imaging modalities, including ultrasound, CT, MRI, and angiography, will be presented. Knowledge of the spectrum of normal and abnormal imaging findings as well as recognition of the common and uncommon complications are essential for accurate diagnosis. CONCLUSION Obstetric complications are a common source of morbidity and mortality for women of reproductive age. Imaging, particularly with ultrasound, is often supplementary to the clinical history and examination in assessing and treating women during the postpartum period. Radiologists should be familiar with the common abnormalities that present in this period and their imaging findings, as well as the wide range of normal appearances the postpartum uterus can assume.

Multimodality Imaging of Ureteric Disease

The proximal ureter (upper) extends from the ureteropelvic junction to where the ureter crosses the sacroiliac joint, the middle ureter courses over the bony pelvis and iliac vessels, and the distal or pelvic (lower) ureter extends from the iliac vessels to the bladder. Benign and malignant lesions can affect the ureter and these may be caused by contiguous involvement from the kidney or bladder. The ureter can be imaged by computed tomography; magnetic resonance imaging; direct pyelography, both antegrade and retrograde; nuclear medicine diuretic scan; and voiding cystourethrography. This article discusses benign, malignant, neoplastic, nonneoplastic processes involving the ureter.

Breast Cancer Imaging with Novel PET Tracers

Whereas (18)F-fluorodeoxyglucose (FDG)-PET/computed tomography has proven to be valuable for breast cancer diagnosis and response evaluation, it is likely that PET radiopharmaceuticals beyond FDG will contribute further to the understanding of breast cancer and thereby further direct breast cancer care. Increasingly specific and quantitative approaches will help direct treatment selection from an ever-expanding and increasing array of targeted breast cancer therapies. This article highlights 4 areas of ongoing research where preliminary patient results look promising: (1) tumor perfusion and angiogenesis, (2) drug delivery and transport, (3) tumor receptor imaging, and (4) early response evaluation. For each area, the biologic background is reviewed and early results are highlighted.

Staging of gynecologic malignancies.

Staging of gynecologic malignancies is essential for proper management; it is important to ensure that the appropriate imaging examinations are performed to ensure the most accurate staging possible. Accurate staging is very crucial for these patients because the treatment plan and prognosis depend primarily upon the staging at the time of initial diagnosis. Many women are understaged on clinical conventional staging examination, even by experienced gynecologic oncologists, because of location of the metastatic disease (eg, under the hemidiaphragm) or because of the small size of tumor deposits. This article will describe the types of imaging examinations that are available for staging, their diagnostic capabilities, proper use, as well as their inherent limitations.

Metastatic colon carcinoma to the prostate gland

We present a case report of a 70-year-old man with a known history of sigmoid adenocarcinoma, treated with chemotherapy and surgical resection of synchronous lung metastases. Four years after initial diagnosis, the patient was diagnosed with metastases to the prostate gland, proven pathologically. To our knowledge, colon adenocarcinoma metastasizing to the prostate has not been previously described on magnetic resonance imaging and positron emission tomography-computed tomography.