title: 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?
abstract: OBJECTIVE
  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 (18)F-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 SUVmax 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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Nuclear Medicine Department, François Baclesse Cancer Centre, Avenue Général Harris, 14076, Cedex 5, Caen, France.
authors.forename: Dimitri
authors.initials: D
authors.lastname: Bellevre
authors.forename: Cécile
authors.initials: C
authors.lastname: Blanc Fournier
authors.forename: Odile
authors.initials: O
authors.lastname: Switsers
authors.forename: Audrey Emmanuelle
authors.initials: AE
authors.lastname: Dugué
authors.forename: Christelle
authors.initials: C
authors.lastname: Levy
authors.forename: Djelila
authors.initials: D
authors.lastname: Allouache
authors.forename: Cédric
authors.initials: C
authors.lastname: Desmonts
authors.forename: Hubert
authors.initials: H
authors.lastname: Crouet
authors.forename: Jean-Marc
authors.initials: JM
authors.lastname: Guilloit
authors.forename: Jean-Michel
authors.initials: JM
authors.lastname: Grellard
authors.forename: Nicolas
authors.initials: N
authors.lastname: Aide
mesh_terms: D000465:Algorithms; D001365:Axilla; D001943:Breast Neoplasms / Q000000981:diagnostic imaging*; D018270:Carcinoma, Ductal, Breast / Q000000981:diagnostic imaging / Q000556:secondary; D005260:Female; D019788:Fluorodeoxyglucose F18; D006801:Humans; D007091:Image Processing, Computer-Assisted / Q000379:methods*; D057230:Limit of Detection; D008207:Lymphatic Metastasis / Q000000981:diagnostic imaging; D008875:Middle Aged; D064847:Multimodal Imaging; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D014057:Tomography, X-Ray Computed
chemical_list: D019275:Radiopharmaceuticals; D019788:Fluorodeoxyglucose F18