Yoko Satoh

PURPOSE: To evaluate the clinical feasibility of high-resolution dedicated breast positron emission tomography (dbPET) with real low-dose 18F-2-fluorodeoxy-D-glucose (18F-FDG) by comparing images acquired with full-dose FDG. MATERIALS AND METHODS: Nine women with no history of breast cancer and previously scanned by dbPET injected with a clinical 18F-FDG dose (3 MBq/kg) were enrolled. They were injected with 50% of the clinical 18F-FDG dose and scanned with dbPET for 10 min for each breast 60 and 90 min after injection. To investigate the effect of the scan start time and acquisition time on image quality, list-mode data were divided into 1, 3, 5, and 7 min (and 10 min with 50% FDG injected) from the start of acquisition and reconstructed. The reconstructed images were visually and quantitatively compared for contrast between mammary gland and fat (contrast) and for coefficient of variation (CV) in the mammary gland. RESULTS: In visual evaluation, the contrast between the mammary gland and fat acquired at a 50% dose for 7 min was comparable and even better in smoothness than that in the images acquired at a 100% dose. No visual difference between the images with a 50% dose was found with scan start times 60 and 90 min after injection. Quantitative evaluation showed a slightly lower contrast in the image at 60 min after 50% dosing, with no difference between acquisition times. There was no difference in CV between conditions; however, smoothness decreased with shorter acquisition time in all conditions. CONCLUSIONS: The quality of dbPET images with a 50% FDG dose was high enough for clinical application. Although the optimal scan start time for improved lesion-to-background mammary gland contrast remained unknown in this study, it will be clarified in future studies of breast cancer patients.

OBJECTIVE: This study aimed to investigate and determine the best deep learning (DL) model to predict breast cancer (BC) with dedicated breast positron emission tomography (dbPET) images. METHODS: Of the 1598 women who underwent dbPET examination between April 2015 and August 2020, a total of 618 breasts on 309 examinations for 284 women who were diagnosed with BC or non-BC were analyzed in this retrospective study. The Xception-based DL model was trained to predict BC or non-BC using dbPET images from 458 breasts of 109 BCs and 349 non-BCs, which consisted of mediallateral and craniocaudal maximum intensity projection images, respectively. It was tested using dbPET images from 160 breasts of 43 BC and 117 non-BC. Two expert radiologists and two radiology residents also interpreted them. Sensitivity, specificity, and area under the receiver operating characteristic curves (AUCs) were calculated. RESULTS: Our DL model had a sensitivity and specificity of 93% and 93%, respectively, while radiologists had a sensitivity and specificity of 77-89% and 79-100%, respectively. Diagnostic performance of our model (AUC = 0.937) tended to be superior to that of residents (AUC = 0.876 and 0.868, p = 0.073 and 0.073), although not significantly different. Moreover, no significant differences were found between the model and experts (AUC = 0.983 and 0.941, p = 0.095 and 0.907). CONCLUSIONS: Our DL model could be applied to dbPET and achieve the same diagnostic ability as that of experts.

BACKGROUND: 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is increasingly applied to the diagnosis of bone marrow failure such as myeloproliferative neoplasm, aplastic anemia, and myelodysplastic syndrome, as well as malignant lymphoma and multiple myeloma. However, few studies have shown a normal FDG uptake pattern. This study aimed to establish a standard of bone marrow FDG uptake by a reproducible quantitative method with fewer steps using deep learning-based organ segmentation. METHODS: Bone marrow PET images were obtained using segmented whole-spine and pelvic bone marrow cavity CT as mask images using a commercially available imaging workstation that implemented an automatic organ segmentation algorithm based on deep learning. The correlation between clinical indicators and quantitative PET parameters, including histogram features, was evaluated. RESULTS: A total of 98 healthy adults were analyzed. The volume of bone marrow PET extracted in men was significantly higher than that in women (p < 0.0001). Univariate and multivariate regression analyses showed that mean of standardized uptake value corrected by lean body mass (SULmean) and entropy in both men and women were inversely correlated with age (all p < 0.0001), and SULmax in women were also inversely correlated with age (p = 0.011). CONCLUSION: A normal FDG uptake pattern was demonstrated by simplified FDG PET/CT bone marrow quantification.

OBJECTIVE: This study aimed to determine the optimal β value of the relaxation control parameter and the post-smoothing filter in the list-mode dynamic row-action maximum likelihood algorithm (LM-DRAMA) to detect early stage breast cancer with high-resolution dedicated breast positron emission tomography (dbPET) in phantom and clinical studies. METHODS: A breast phantom containing four spheres (5, 7.5, 10, and 16 mm in diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background ratio, 8:1) and scanned on a dbPET scanner. The images were reconstructed using LM-DRAMA with different β values (5, 20, or 100) and Gaussian post-filters (0, 0.78, 1.17, 1.56, 1.95, or 2.34 mm). Other conditions were according to those routinely used (1 iteration and 128 subsets including attenuation and scatter correction). Image quality was evaluated visually and by computing the coefficient of variation of the background (CVBG), detectability index (DI), and contrast recovery coefficient. Parameters optimized in these phantom studies were applied to 25 clinical data sets. Variabilities for different reconstruction methods in visual scores, the maximum standardized uptake value of breast cancer, and the tumor-to-background uptake ratio were estimated. RESULTS: The reconstruction images of the phantom with higher β values and smaller post-filters yielded higher visual scores for detectability and DI and lower smoothness and CVBG scores. Based on the phantom study, the β values and post-filter were optimized for clinical dbPET images except for β5 and 2.34 mm post-filter. Applying the other reconstructions to clinical studies showed that β100 provided higher quantitative parameter values. The detectability of lesions was similar for β100 and β20 and decreased with larger post-filters. The lesion detection rate was similar for β100 and β20 and decreased with larger post-filter. CONCLUSION: The relaxation coefficient factor β20 and a 0.78- or 1.17-mm post-filter were optimal for dbPET image reconstruction with balanced spatial resolution and noise. However, they should be selected according to the impact on the dbPET image and the purpose of the examination.

Breast positron emission tomography (PET) has had insurance coverage when performed with conventional whole-body PET in Japan since 2013. Together with whole-body PET, accurate examination of breast cancer and diagnosis of metastatic disease are possible, and are expected to contribute significantly to its treatment planning. To facilitate a safer, smoother, and more appropriate examination, the Japanese Society of Nuclear Medicine published the first edition of practice guidelines for high-resolution breast PET in 2013. Subsequently, new types of breast PET have been developed and their clinical usefulness clarified. Therefore, the guidelines for breast PET were revised in 2019. This article updates readers as to what is new in the second edition. This edition supports two different types of breast PET depending on the placement of the detector: the opposite-type (positron emission mammography; PEM) and the ring-shaped type (dedicated breast PET; dbPET), providing an overview of these scanners and appropriate imaging methods, their clinical applications, and future prospects. The name "dedicated breast PET" from the first edition is widely used to refer to ring-shaped type breast PET. In this edition, "breast PET" has been defined as a term that refers to both opposite- and ring-shaped devices. Up-to-date breast PET practice guidelines would help provide useful information for evidence-based breast imaging.

BACKGROUND: Using phantoms and clinical studies in prone hanging breast imaging, we assessed the image quality of a commercially available dedicated breast PET (dbPET) at the detector's edge, where mammary glands near the chest wall are located. These are compared to supine PET/CT breast images of the same clinical subjects. METHODS: A breast phantom with four spheres (16-, 10-, 7.5-, and 5-mm diameter) was filled with 18F-fluorodeoxyglucose solution (sphere-to-background activity concentration ratio, 8:1). The spheres occupied five different positions from the top edge to the centre of the detector and were scanned for 5 min in each position. Reconstructed images were visually evaluated, and the contrast-to-noise ratio (CNR), contrast recovery coefficient (CRC) for all spheres, and coefficient of variation of the background (CVB) were calculated. Subsequently, clinical images obtained with standard supine PET/CT and prone dbPET were retrospectively analysed. Tumour-to-background ratios (TBRs) between breast cancer near the chest wall (close to the detector's edge; peripheral group) and at other locations (non-peripheral group) were compared. The TBR of each lesion was compared between dbPET and PET/CT. RESULTS: Closer to the detector's edge, the CNR and CRC of all spheres decreased while the CVB increased in the phantom study. The disadvantages of this placement were visually confirmed. Regarding clinical images, TBR of dbPET was significantly higher than that of PET/CT in both the peripheral (12.38 ± 6.41 vs 6.73 ± 3.5, p = 0.0006) and non-peripheral (12.44 ± 5.94 vs 7.71 ± 7.1, p = 0.0183) groups. There was no significant difference in TBR of dbPET between the peripheral and non-peripheral groups. CONCLUSION: The phantom study revealed poorer image quality at < 2-cm distance from the detector's edge than at other more central parts. In clinical studies, however, the visibility of breast lesions with dbPET was the same regardless of the lesion position, and it was higher than that in PET/CT. dbPET has a great potential for detecting breast lesions near the chest wall if they are at least 2 cm from the edge of the FOV, even in young women with small breasts.

OBJECTIVE: The aim of this study was to evaluate the diagnostic ability of support vector machine (SVM) for early breast cancer (BC) using dedicated breast positron emission tomography (dbPET). METHODS: We evaluated 116 abnormal fluorodeoxyglucose (FDG) uptakes less than 2 cm on dbPET images in 105 women. Fluorodeoxyglucose uptake patterns and quantitative PET parameters were compared between BC and noncancer groups. Diagnostic accuracy of the SVM model including quantitative parameters was compared with that of visual assessment based on FDG-uptake pattern. RESULTS: Age, maximum standardized uptake value, peak standardized uptake value, total lesion glycolysis, metabolic tumor volume, and lesion-to-contralateral background ratio were significantly different between BC and noncancer groups. Area under the curve, sensitivity, specificity, and accuracy for FDG-uptake pattern of visual assessment were 0.77, 0.57, 0.77, and 0.71, respectively; those of an SVM model including age, maximum standardized uptake value, total lesion glycolysis, and lesion-to-contralateral background ratio were 0.89, 0.94, 0.77, and 0.85, respectively. CONCLUSIONS: Support vector machine showed high diagnostic performance for BC using dbPET.

Objective: This retrospective study aimed to compare the ability to classify tumor characteristics of breast cancer (BC) of positron emission tomography (PET)-derived texture features between dedicated breast PET (dbPET) and whole-body PET/computed tomography (CT). Methods: Forty-four BCs scanned by both high-resolution ring-shaped dbPET and whole-body PET/CT were analyzed. The primary BC was extracted with a standardized uptake value (SUV) threshold segmentation method. On both dbPET and PET/CT images, 38 texture features were computed; their ability to classify tumor characteristics such as tumor (T)-category, lymph node (N)-category, molecular subtype, and Ki67 levels was compared. The texture features were evaluated using univariate and multivariate analyses following principal component analysis (PCA). AUC values were used to evaluate the diagnostic power of the computed texture features to classify BC characteristics. Results: Some texture features of dbPET and PET/CT were different between Tis-1 and T2-4 and between Luminal A and other groups, respectively. No association with texture features was found in the N-category or Ki67 level. In contrast, receiver-operating characteristic analysis using texture features' principal components showed that the AUC for classification of any BC characteristics were equally good for both dbPET and whole-body PET/CT. Conclusions: PET-based texture analysis of dbPET and whole-body PET/CT may have equally good classification power for BC.

PURPOSE: To determine the clinically acceptable level of reduction in the injected fluorine-18 (18F)-labeled fluorodeoxyglucose (18F-FDG) dose in dedicated breast positron emission tomography (dbPET). METHODS: A breast phantom with four spheres exhibiting various diameters (5, 7.5, 10, and 16 mm), a background 18F-FDG radioactivity of 2.28 kBq/mL, and a sphere-to-background radioactivity ratio of 8:1 was used. True dose-reduced dbPET images were obtained by data acquisition for 20 min in list mode at multiple time points over 7 h of radioactive decay. Simulated dose-reduced images were generated by reconstruction with a portion of the list mode acquisition data. True and simulated dose-reduced images were visually and quantitatively compared. On the basis of the phantom study, dbPET images for 32 breasts of 28 women with abnormal uptake were generated after simulated reduction of the injected 18F-FDG doses; these images were compared with those acquired using current clinical doses. RESULTS: There were no qualitative differences between true and simulated dose-reduced phantom images. The phantom study revealed that the minimal required dose was 12.5% for the detection of 5-mm spheres and 25% for precise semi-quantification of FDG in the spheres. The 7-min reconstruction with a 100% dose was defined as the reference for the clinical study. The image quality and lesion conspicuity were clinically acceptable for the 25% dose images. Lesion detectability on the 12.5% dose images was maintained despite image quality degradation. CONCLUSIONS: In summary, 25% of the standard 18F-FDG dose for dbPET can provide a clinically acceptable image quality, while 12.5% of the standard dose results in acceptable quality in terms of lesion detection when lesions are located at a sufficient distance from the edge of the dbPET detector.

OBJECTIVE: The purposes of this study were to evaluate the diagnostic performance of dedicated breast PET (dbPET) in cases of unexpected uptake and to define parameters associated with malignancy. MATERIALS AND METHODS: There are two types of high-resolution dbPET systems. One has two platelike detectors that compress the breast. This study was conducted with the other type, on which the patient lies prone and the breast hangs through a ring without compression. In total, 627 consecutively registered women underwent 18F-FDG PET/CT and dbPET for pretherapeutic or posttherapeutic evaluation of breast cancer, prior suspicion of breast cancer, or cancer screening. Areas of abnormal FDG uptake, excluding known breast cancers, were analyzed. Uptake was morphologically categorized as focus, mass, or non-mass. Quantitative values were obtained, including the maximum standardized uptake value (SUVmax), peak SUV (SUVpeak), total lesion glycolysis (TLG), metabolic tumor volume (MTV), and lesion-to-background ratio (LBR). Clinical parameters were also assessed. Parameters were compared between breast cancer and noncancer groups; multivariate logistic regression analysis was performed. RESULTS: Of 40 instances of abnormal uptake, 13 were breast cancer. Morphologic features differed between cancer and noncancer groups (p = 0.0122). Among the cancers, 76.9% (10/13) had mass, 15.4% (2/13) had nonmass, and 7.7% (1/13) had focus uptake. Of noncancerous findings, 3.7% (1/27) were mass, 40.7% (11/27) nonmass, and 55.6% (15/27) focus uptake. SUVpeak (p = 0.0234), TLG (p = 0.0017), MTV (p = 0.004), and LBR (p = 0.0432) also differed between groups. Results of multivariate analysis indicated that morphologic category at dbPET was independently associated with malignancy. CONCLUSION: Morphologic features of abnormal uptake at dbPET are associated with breast cancer and may be useful for diagnosing lesions of unknown histologic composition.

PURPOSE: To evaluate the prognostic importance and predictive performance of volume-based parameters of fluorine 18 fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in patients with stage I non-small cell lung cancer (NSCLC) after stereotactic body radiation therapy (SBRT). MATERIALS AND METHODS: This study had institutional review board approval. All patients gave written informed consent for SBRT as well as for future anonymous use of clinical data. Data in 88 patients with stage I NSCLC (68 patients with T1N0M0 disease and 20 with T2aN0M0 disease) who had undergone FDG PET/CT and then SBRT were retrospectively evaluated. Seventy-seven tumors were histopathologically proved (48 adenocarcinomas, 24 squamous cell carcinomas, and five unspecified non-small cell carcinomas), and the remaining 11 tumors were diagnosed clinically without histopathologic diagnosis. Maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were analyzed. The MTV of the primary tumor was calculated as all voxels with an SUV of 2.5 or greater within the isocontour line, while TLG was calculated as MTV multiplied by the average SUV, by using fixed thresholds of either 50% (TLG50) or 60% (TLG60) of the maximum intratumoral FDG activity. The prognostic importance of PET parameters and other clinicopathologic variables (age, sex, tumor size, tumor location [peripheral or central], and biologically effective dose) was assessed by using Cox proportional hazards regression analysis of overall survival (OS) and disease-free survival (DFS) for both univariate and multiple-variable analyses. RESULTS: The median follow-up period was 33 months. At 3 years, OS and DFS were 70.0% and 49.7%, respectively. In the univariate analyses, SUVmax (P = .001), MTV (P = .002), TLG50 (P = .001), and TLG60 (P < .001) were found to be significantly associated with DFS. In multiple variable analysis, these parameters were also significantly associated with DFS (P = .011 for SUVmax, P = .010 for MTV, P = .004 for TLG50, and P = .005 for TLG60). Only volumetric parameters (MTV, TLG50, and TLG60) were significant indicators of DFS in patients with tumors larger than 3 cm. CONCLUSION: SUVmax, MTV, and TLG at FDG PET/CT have a prognostic role for patients with NSCLC treated with SBRT. When tumors are larger than 3 cm, only MTV and TLG are predictive of DFS.