DOI: 10.1148/radiol.2473061678
(Radiology 2008;247:651-657.)
© RSNA, 2008
Breast-specific Gamma Imaging as an Adjunct Imaging Modality for the Diagnosis of Breast Cancer1
Rachel F. Brem, MD,
Angelique C. Floerke, MD, PharmD,
Jocelyn A. Rapelyea, MD,
Christine Teal, MD,
Tricia Kelly, MD, and
Vivek Mathur, MD
1 From the Departments of Radiology (R.F.B., A.C.F., J.A.R., V.M.) and Surgery (C.T., T.K.), George Washington University, 2150 Pennsylvania Ave NW, Washington, DC 20037. Received October 4, 2006; revision requested December 5; revision received February 13, 2007; accepted March 19; final version accepted November 12. Supported in part by Bristol Myers Squibb.
Address correspondence to R.F.B. (e-mail: rbrem{at}mfa.gwu.edu).
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ABSTRACT
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Purpose: To retrospectively determine the sensitivity and specificity of breast-specific gamma imaging (BSGI) for the detection of breast cancer by using pathologic results as the reference standard.
Materials and Methods: This study was Institutional Review Board approved and Health Insurance Portability and Accountability Act compliant. Informed consent was obtained for participants who were not imaged as part of their clinical protocol but were participating in other Institutional Review Board–approved studies that used BSGI. A retrospective review of 146 women (aged 32–98 years) undergoing BSGI and breast biopsy was performed. Patients underwent BSGI with intravenous injection of 30 mCi (1110 MBq) of technetium 99 (99mTc)-sestamibi and were imaged in craniocaudal and mediolateral oblique projections. Study images were assigned scores, and scores were classified as positive (focal increased radiotracer uptake) or negative (no uptake or scattered heterogeneous physiologic uptake) and compared with biopsy results. The sensitivity, specificity, and positive and negative predictive values were determined.
Results: In 146 patients, 167 lesions underwent biopsy, of which 83 (16 ductal carcinoma in situ [DCIS] and 67 invasive cancers) were malignant. Of 84 nonmalignant lesions, 82 were benign and two showed atypical histologic results (one atypical lobular hyperplasia and one lobular carcinoma in situ). BSGI helped detect cancer in 80 of 83 malignant lesions with a sensitivity of 96.4% (95% confidence interval [CI]: 92%, 99%) and correctly identified 50 of 84 nonmalignant lesions as negative for cancer with a specificity of 59.5% (95% CI: 49%, 70%). The positive predictive value for 80 of 114 malignant lesions with a BSGI examination with findings positive for cancer was 68.8% (95% CI: 60%, 78%) and the negative predictive value for 50 of 53 nonmalignant lesions was 94.3% (95% CI: 88%, 99%). The smallest invasive cancer and DCIS detected were both 1 mm. BSGI helped detect occult cancer not visualized at mammography or ultrasonography in six patients.
Conclusion: BSIG has high sensitivity (96.4%) and moderate specificity (59.5%) helping detect breast cancers.
© RSNA, 2008
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INTRODUCTION
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Mammography remains the imaging modality of choice for breast cancer screening. The overall sensitivity of mammography has been reported to be 78%–85%; however, the sensitivity of mammography decreases to 42%–68% in women with dense breasts (1,2). In addition, the false-positive rate of screening mammography is 15%–30%, leading to many benign findings at biopsy. Limitations in the sensitivity and specificity of screening mammography led to the investigation of adjunct breast imaging modalities.
The use of technetium 99m (99mTc)-sestamibi for breast cancer detection was reported by Aktolun et al (3) in 1992 during its evaluation as a cardiac imaging agent. In 1994, Khalkhali et al (4) reported on 99mTc-sestamibi scintimammography in patients with suspected breast cancer. Since that time, multiple techniques that used both planar and single photon emission computed tomographic radionuclide imaging with a general-purpose gamma camera for the detection of breast cancer have been evaluated. These techniques have yielded an average sensitivity of 84% and specificity of 86% as reported by Taillefer (5) in a meta-analysis of 5660 patients. In comparison with mammography, the sensitivity of 99mTc-sestamibi scintimammography is independent of breast density (6–8). In addition, scintimammography has not shown increased uptake in women with architectural distortion or scarring from a prior procedure (9).
99mTc-sestamibi scintimammography performed with a general-purpose gamma camera is limited by the inability to reliably image cancers smaller than 1 cm owing to its intrinsic resolution. The sensitivity of scintimammography performed with a general-purpose gamma camera for cancers 1 cm or smaller is 35%–65% (10–15). Therefore, although it is possible to detect larger cancers, it is more difficult, if at all possible, to diagnose smaller and thereby earlier breast cancers by using a general-purpose gamma camera.
As a result of the potential of scintimammography to help improve diagnosis of breast cancer, even accounting for the limitations in resolution and design of the traditional gamma camera for breast imaging, high-resolution breast-specific gamma cameras have been developed. The use of high-resolution, small-field-of-view breast-specific gamma imaging (BSGI) has been shown to increase the sensitivity of nuclear breast imaging (16–19). One study demonstrated an increase in sensitivity from 85% to 92% for lesions larger than 1 cm and from 47% to 67% for lesions smaller than 1 cm when using BSGI as compared with a general-purpose gamma camera (16). It is worth noting that in this pilot study, all patients were imaged first with the traditional gamma camera, followed by BSGI when the radiotracer activity was no longer optimal, and women with both dense and fatty breasts were included (16). Cancers as small as 6 mm were detected with the high-resolution gamma camera when screening women at increased risk for breast cancer (17).
The purpose of our study was to retrospectively determine the sensitivity and specificity of BSGI to help detect breast cancer by using pathologic results as the reference standard.
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MATERIALS AND METHODS
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This study was partially supported by Bristol Myers Squibb (Washington, DC) with financial as well as in-kind support of the radiotracer used. R.F.B. is financially invested in Dilon Technologies (Newport News, Va). Any data and information that might present a conflict of interest were under the control of the other authors. R.F.B. is now a member of the board of managers of Dilon Technologies but was not when this study was performed.
From August 2001 to March 2006, 146 consecutive women (mean age, 53.1 years; range, 32–98 years; standard deviation, 11.7 years; median, 53.5 years) underwent BSGI and biopsy retrieval. Clinical indications for BSGI included a palpable lesion with no mammographic correlation; diagnosis of multicentricity and/or multifocality in women with biopsy-proved cancer; asymmetric density seen at mammography with no corresponding ultrasonographic (US), magnetic resonance (MR) imaging, or clinical finding; and screening of women at high risk for breast cancer, defined as women with a 1.66% probability of cancer in the next 5 years as calculated by the Breast Cancer Risk Assessment Profile (20–22). Our retrospective study was approved by the Institutional Review Board with a waiver of informed consent and waiver of Heath Insurance Portability and Accountability Act authorization. Informed consent was obtained from participants who were not being imaged as part of their clinical protocol but were participating in other Institutional Review Board–approved and Heath Insurance Portability and Accountability Act–compliant studies in which BSGI was used.
BSGI and Interpretation
A high-resolution small-field-of-view breast-specific gamma camera (6800; Dilon Technologies) was used to obtain images. Patients received an intravenous injection of 25–30 mCi (925–1110 MBq) of 99mTc-sestamibi (Miraluma; Du Pont Pharma, Billerica, Mass) in the antecubital vein. If the patient had a known breast cancer finding prior to BSGI examination, the injection was performed in the contralateral arm to avoid the ambiguity of increased radiotracer uptake in the axilla if there was some extravasation of radiotracer during the injection. Patients were placed in the seated position and craniocaudal (CC) and mediolateral oblique (MLO) images of the breasts were obtained at 7–10 minutes per image. Gamma images were categorized for focal radiotracer uptake. Images were categorized as normal (score of 1), with no focal or diffuse uptake; benign (score of 2), with minimal patchy uptake; probably benign (score of 3), with minimal patchy uptake with some areas of more focal uptake; probably abnormal (score of 4), with mild focal radiotracer uptake; and abnormal (score of 5), with marked focal radiotracer uptake. The degree of uptake (eg, mild, moderate) was a subjective assessment. Scores of 1, 2, and 3 were classified as negative, and scores of 4 and 5 were classified as positive. Images were independently read by two radiologists (R.F.B. and J.A.R., with 8 and 5 years experience in BSGI interpretation, respectively). Radiologists were blinded to the biopsy results. Discrepancies were resolved with consensus. Pathologic reports were retrospectively reviewed by one of two radiologists (R.F.B., J.A.R.).
Pathologic Diagnosis as Reference Standard
Pathologic diagnosis of suspicious lesions was determined by using breast tissue obtained from percutaneous biopsy retrieval with either US guidance by using a 14-gauge spring-loaded needle (Achieve; Allegiance Health Care, McGraw Park, Ill) or stereotactic guidance by using a 9-gauge vacuum-assisted biopsy needle (ATEC; Suros Surgical Systems, Indianapolis, Ind) and subsequent surgical excision following biopsy results positive for cancer. Patients with occult lesions detected by using BSGI underwent targeted reevaluation with second-look US and underwent US-guided biopsy retrieval. During retrospective review of pathologic results (A.C.F.), histologic findings, size of malignancies, and ductal carcinoma in situ (DCIS) grade as applicable were recorded when available.
Statistical Analysis
The sensitivity, specificity, and positive and negative predictive values of BSGI to help detect breast cancer were calculated by comparing the BSGI results with the pathologic diagnosis. Because several patients had two or more lesions, statistical independence cannot be assumed. Therefore, the method of generalized estimating equations, which allows for nonindependent data (1), was used to estimate the above statistics, as well as their 95% confidence intervals (CIs). Calculations were made on the basis of an exchangeable working correlation matrix and model-based standard errors of the mean. Statistical analysis was performed by using software (SAS, version 9.1; SAS Institute, Cary, NC) (2).
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RESULTS
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There were 167 biopsy samples retrieved from lesions in 146 patients (Fig 1). Eighteen patients underwent biopsy of multiple lesions: one patient with four lesions (bilateral breasts), one patient with three lesions (same breast), and 16 patients with two lesions (12 patients with biopsies of bilateral breasts).
Malignant and Benign Lesions
There were 83 malignant lesions identified, of which 67 (80.7%) were invasive cancers and 16 (19.3%) were DCIS. Of the 84 nonmalignant lesions, 82 (97.6%) were benign, with no associated increased risk of cancer, and two were benign lesions of the type that are associated with increased risk of breast cancer: atypical lobular hyperplasia (n = 1, 1.2%) and lobular carcinoma in situ (n = 1, 1.2%). Pathologic findings for atypical lobular hyperplasia and lobular carcinoma in situ were confirmed at excisional biopsy. The overall prevalence of disease was 49.7%. In 83 malignant lesions (invasive carcinoma or DCIS), BSGI helped identify 80 as malignant, resulting in a sensitivity of 96.4% (95% CI: 92%, 99%). In 84 nonmalignant lesions, BSGI findings were negative for malignancy in 50 and positive for malignancy in the other 34, resulting in a specificity of 59.5% (95% CI: 49%, 70%).
Of 114 lesions with BSGI examination findings, 80 were invasive cancer or DCIS, resulting in a positive predictive value of 68.8% (95% CI: 60%, 78%). Of 53 lesions with negative BSGI examination findings for malignancy, 50 had no evidence of DCIS or invasive cancer, resulting in a negative predictive value of 94.3% (95% CI: 88%, 99%).
Of 67 invasive carcinoma lesions, BSGI helped identify cancer in 65, resulting in a sensitivity of 97.0% (95% CI: 89%, 99%) (Table 1 and Figs 2 and 3). DCIS was identified by using BSGI in 15 of 16 lesions, resulting in a sensitivity of 93.8% (95% CI: 69%, 99%) (Fig 4). The 15 DCIS lesions were graded as high (n = 4), intermediate (n = 7), low (n = 3), or not available (n = 1).
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Figure 2a: BSGI of 39-year-old woman with new palpable mass in right breast. Pathologic findings showed 1.6-cm infiltrating ductal carcinoma. (a) CC and (b) MLO images of breast show focal increased radiotracer uptake corresponding to cancer (arrow).
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Figure 2b: BSGI of 39-year-old woman with new palpable mass in right breast. Pathologic findings showed 1.6-cm infiltrating ductal carcinoma. (a) CC and (b) MLO images of breast show focal increased radiotracer uptake corresponding to cancer (arrow).
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Figure 3a: BSGI of 46-year-old woman. (a) CC and (b) MLO views show focal increased radiotracer uptake (arrow) in upper right breast. Pathologic findings showed 0.6-cm infiltrating lobular carcinoma with extensive lobular carcinoma in situ. Left (c) CC and (d) MLO views show focal increased radiotracer uptake in upper outer breast (arrow). Pathologic findings showed 3.7-cm infiltrating lobular carcinoma.
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Figure 3b: BSGI of 46-year-old woman. (a) CC and (b) MLO views show focal increased radiotracer uptake (arrow) in upper right breast. Pathologic findings showed 0.6-cm infiltrating lobular carcinoma with extensive lobular carcinoma in situ. Left (c) CC and (d) MLO views show focal increased radiotracer uptake in upper outer breast (arrow). Pathologic findings showed 3.7-cm infiltrating lobular carcinoma.
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Figure 3c: BSGI of 46-year-old woman. (a) CC and (b) MLO views show focal increased radiotracer uptake (arrow) in upper right breast. Pathologic findings showed 0.6-cm infiltrating lobular carcinoma with extensive lobular carcinoma in situ. Left (c) CC and (d) MLO views show focal increased radiotracer uptake in upper outer breast (arrow). Pathologic findings showed 3.7-cm infiltrating lobular carcinoma.
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Figure 3d: BSGI of 46-year-old woman. (a) CC and (b) MLO views show focal increased radiotracer uptake (arrow) in upper right breast. Pathologic findings showed 0.6-cm infiltrating lobular carcinoma with extensive lobular carcinoma in situ. Left (c) CC and (d) MLO views show focal increased radiotracer uptake in upper outer breast (arrow). Pathologic findings showed 3.7-cm infiltrating lobular carcinoma.
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Figure 4a: BSGI of 73-year-old woman shows (a) CC and (b) MLO views of focal radiotracer uptake (arrow) in central left breast. Pathologic findings show cribriform and micropapillary DCIS, which was multifocal; therefore, size was not determined.
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Figure 4b: BSGI of 73-year-old woman shows (a) CC and (b) MLO views of focal radiotracer uptake (arrow) in central left breast. Pathologic findings show cribriform and micropapillary DCIS, which was multifocal; therefore, size was not determined.
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Lesion Size
Of the lesions with available sizes, the mean size of invasive cancer detected by using BSGI was 20 mm (n = 56; standard deviation, 14 mm; median, 15 mm) and the mean size of DCIS detected was 18 mm (n = 9; standard deviation, 18 mm; median, 7 mm). The sensitivity of BSGI as a function of cancer size varied (Table 2). The smallest invasive cancer and the smallest DCIS, both detected by using BSGI, were 1 mm. BSGI correctly identified 16 of 18 cancers (88.9%) smaller than 1 cm.
False-Positive Lesions
There were 34 false-positive lesions (Table 3), defined as a BSGI examination with positive findings and benign or atypical pathologic findings. Fibrocystic change was the most common pathologic finding reported. Eight patients with a false-positive result had undergone biopsy retrieval in the preceding 2 months and demonstrated increased levels of radiotracer uptake.
BSGI Findings Negative, Other Study Findings Positive
Three histopathologically proved cancers (one DCIS and two invasive carcinomas) detected by using mammography, US, or MR imaging were not detected by using BSGI. They ranged in size from 3 to 10 mm. The DCIS that was not detected was of high grade, measured 10 mm, and was detected at mammography by noting retroareolar microcalcifications on a screening mammogram. The two invasive cancers that were not detected by using BSGI were infiltrating ductal carcinomas. One cancer measured 7 mm, was detected mammographically in the axillary tail, and was then palpated by using targeted physical examination. The other measured 3 mm and was an incidental cancer found during prophylactic mastectomy in a patient with a contralateral breast cancer. It was not identified with mammography, US, or clinical examination.
Multicentric and Multifocal Disease
Eleven (16.7%) of 66 patients with cancer had multicentric or multifocal disease. BSGI helped detect occult cancers not seen at mammography or US in six (7.2%) patients. In these six patients, the lesion was found at second-look US and underwent US-guided biopsy (Fig 5).
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Figure 5a: BSGI of 73-year-old woman shows vague mammographic architectural distortion in lower outer right breast. (a) CC and (b) MLO views show focal radiotracer uptake (arrows). Pathologic findings showed multifocal DCIS with no focus larger than 4 mm. Left breast (c) CC and (d) MLO views demonstrate small focal area of increased radiotracer uptake (arrows). Patient had normal mammogram and initial US findings. Second-look US identified vague hypoechoic area. Surgical excisional biopsy results showed single 4-mm focus of low-grade DCIS, which was occult and unidentified prior to BSGI.
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Figure 5b: BSGI of 73-year-old woman shows vague mammographic architectural distortion in lower outer right breast. (a) CC and (b) MLO views show focal radiotracer uptake (arrows). Pathologic findings showed multifocal DCIS with no focus larger than 4 mm. Left breast (c) CC and (d) MLO views demonstrate small focal area of increased radiotracer uptake (arrows). Patient had normal mammogram and initial US findings. Second-look US identified vague hypoechoic area. Surgical excisional biopsy results showed single 4-mm focus of low-grade DCIS, which was occult and unidentified prior to BSGI.
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Figure 5c: BSGI of 73-year-old woman shows vague mammographic architectural distortion in lower outer right breast. (a) CC and (b) MLO views show focal radiotracer uptake (arrows). Pathologic findings showed multifocal DCIS with no focus larger than 4 mm. Left breast (c) CC and (d) MLO views demonstrate small focal area of increased radiotracer uptake (arrows). Patient had normal mammogram and initial US findings. Second-look US identified vague hypoechoic area. Surgical excisional biopsy results showed single 4-mm focus of low-grade DCIS, which was occult and unidentified prior to BSGI.
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Figure 5d: BSGI of 73-year-old woman shows vague mammographic architectural distortion in lower outer right breast. (a) CC and (b) MLO views show focal radiotracer uptake (arrows). Pathologic findings showed multifocal DCIS with no focus larger than 4 mm. Left breast (c) CC and (d) MLO views demonstrate small focal area of increased radiotracer uptake (arrows). Patient had normal mammogram and initial US findings. Second-look US identified vague hypoechoic area. Surgical excisional biopsy results showed single 4-mm focus of low-grade DCIS, which was occult and unidentified prior to BSGI.
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DISCUSSION
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Our experience with BSGI as an adjunct imaging modality to help detect breast cancer showed an overall sensitivity (96.4%) higher than that of standard gamma camera scintimammography (84%) and previously reported BSGI (79%) (5,16). The sensitivity of BSGI is comparable to MR (88%) imaging (23). Patients in our study were imaged immediately after 99mTc-sestamibi injection, whereas the patients in the prior BSGI studies were imaged 1–1.5 hours after injection. Delayed imaging may have decreased sensitivity because of increased washout of 99mTc-sestamibi from the cancer and may, at least in part, explain the improved sensitivity demonstrated in our study. Additionally, the prior studies used a prototypic gamma camera, whereas our study used a commercially available high-resolution breast-specific gamma camera.
In the setting of 49.7% prevalence of disease in our population, the positive predictive value is 68.8%. The high prevalence of disease reflects the referral bias for BSGI in high-risk patients. In addition, the specificity of BSGI is moderate (59.5%), which is lower than the high (93.3%) specificity previously reported (16). The patient population changed from 2001 to 2005 from more highly selected patients with palpable findings to patients with inconclusive mammographic and US studies and no palpable findings. As a result, specificity may have decreased to numbers that are more representative of how this modality will be used in practice.
The capability to help detect subcentimeter (defined as <1 cm) cancers has been a criticism of gamma imaging of the breast. The sensitivity for subcentimeter lesions (88.9%) is higher than previously reported with scintimammography (35%–65%) and MR imaging (79.1%) (10–16,23). It is comparable to the 86% sensitivity of BSGI in helping detect subcentimeter cancers, as reported by Rhodes et al (19). Previously, the smallest reported lesion detected by using BSGI was 6 mm (17). In our study, five invasive cancers and three DCIS lesions measuring less than 5 mm were detected. The improved sensitivity with BSGI as compared with scintimammography results, at least in part, from the improved spatial resolution of the breast-specific gamma camera, as well as the decreased lesion-to-detector distance. The ability to detect small subcentimeter breast cancers should aid in the early detection of breast cancer, including occult foci. Additional studies with larger study populations are needed to further define the sensitivity of BSGI for both in situ and invasive subcentimeter lesions.
Our study demonstrates that BSGI has a sensitivity of 93.8% for the detection of DCIS and 97.0% for the detection of invasive cancers. This sensitivity is comparable to that reported in MR imaging for invasive cancers (90.9%) and better than that reported for DCIS (73%) (23). Although larger study populations are needed, these findings support the potential of BSGI. MR imaging is increasingly being used as an adjunct imaging modality to improve the detection and diagnosis of breast cancer, to help evaluate high-risk women, to help detect additional occult foci of breast cancer in women with biopsy-proved cancer, and to help evaluate patients with equivocal mammographic or clinical findings. Our study supports the use of BSGI because MR imaging would be used in clinical practice with equal sensitivity and higher specificity. An advantage of BSGI is the greater comfort of the patient, with the study being performed with the patient sitting as opposed to being placed in an MR imager. Additionally, BSGI results in four to eight images as compared with several hundred images in a breast MR examination, leading to a concomitant decrease in interpretation time. In our practice, BSGI has been integrated in the daily evaluation of patients, as appropriate.
The detection of occult cancers is an important goal of developing adjunct imaging modalities to mammography. BSGI helped detect six occult cancers not detected by using mammography or US in six women. Therefore, 7.2% of women with cancer were found to have additional foci of cancer that would not have been detected with more conventional imaging modalities. Given the high sensitivity of BSGI, it can be considered as a presurgical examination in patients with biopsy-proved cancer to look for additional foci as well as contralateral breast cancer. In our practice, nearly all women with biopsy-proved cancer are imaged with BSGI to help detect occult foci of cancer.
There were limitations to our study. It was a retrospective study with patients of varying pretest probability of cancer who had undergone BSGI imaging for different reasons. In addition, the areas of increased uptake on BSGI were assumed to represent the areas of abnormality seen during other imaging examinations and the areas that underwent biopsy. While we made efforts to ensure the same, to date, there is no means of fusing BSGI with mammography or US.
In conclusion, BSGI is a promising adjunct imaging modality with high sensitivity and moderate specificity to help detect breast cancers, including subcentimeter invasive and in situ cancers. Additional multi-institutional studies are needed with larger study sample sizes to further evaluate BSGI.
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ADVANCE IN KNOWLEDGE
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- Breast-specific gamma imaging (BSGI) has high sensitivity (96.4%) in helping detect breast cancer.
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IMPLICATION FOR PATIENT CARE
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- BSGI has the potential to improve breast cancer diagnosis.
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ACKNOWLEDGMENTS
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The authors thank Joyce Raub, RT, for performing the BSGI studies and maintaining the patient database and Kristen Dixon, MS, for helping with the manuscript. The authors also are grateful for the statistical analysis performed by Sam Simmens, PhD.
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FOOTNOTES
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Abbreviations: BSGI = breast-specific gamma imaging • CC = craniocaudal • CI = confidence interval • DCIS = ductal carcinoma in situ • MLO = mediolateral oblique
See Materials and Methods for pertinent disclosures.
Author contributions: Guarantors of integrity of entire study, R.F.B., V.M.; study concepts/study design or data acquisition or data analysis/interpretation, all authors; manuscript drafting or manuscript revision for important intellectual content, all authors; approval of final version of submitted manuscript, all authors; literature research, R.F.B., A.C.F., J.A.R., C.T.; clinical studies, R.F.B., J.A.R., C.T., T.K., V.M.; statistical analysis, R.F.B., A.C.F., J.A.R., V.M.; and manuscript editing, all authors
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W. Riordan, R. F. Brem, A. C. Floerke, and J. M. Rapelyea
Breast-specific Gamma Imaging for Detection of Breast Cancer
Radiology,
April 1, 2009;
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R. F. Brem, M. Ioffe, J. A. Rapelyea, K. G. Yost, J. M. Weigert, M. L. Bertrand, and L. H. Stern
Invasive Lobular Carcinoma: Detection with Mammography, Sonography, MRI, and Breast-Specific Gamma Imaging
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[Abstract]
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W. A. Berg
Tailored Supplemental Screening for Breast Cancer: What Now and What Next?
Am. J. Roentgenol.,
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[Abstract]
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G. S. Dorfman, D. C. Sullivan, M. D. Schnall, L. M. Matrisian, and for the Translational Research Working Group
The Translational Research Working Group Developmental Pathway for Image-Based Assessment Modalities
Clin. Cancer Res.,
September 15, 2008;
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5678 - 5684.
[Abstract]
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TOP
ABSTRACT
INTRODUCTION
