Schmidt et al. (2008)

Schmidt et al. (2008)
Design: Prospective case series (diagnostic), evidence level: 3
Country: Germany
Inclusion criteria:
Women with a history of breast cancer presenting with some or all of the following: clinical symptoms, imaging results, pain, raised serum levels of tumour markers (CEA, CA, CA 15–3) which were suggestive of cancer recurrence.
Exclusion criteria:
Women who were in receipt of chemotherapy or radiotherapy prior to the study were excluded from the data analysis.
Number of patients = 33. Range: 24 to 79 years. Mean age: 55 years.
Whole body MRI (WB-MRI) was given on a 1.5T scanner (n = 23 patients) and images were obtained from head to mid-calves in coronal and sagittal orientations. Ten patients had imaging with a 3T scanner. Coronal T1w- TSE- and STIR-sequences, HASTE imaging of lungs, contrast-enhanced T1w- and T2w- TSE-sequences of the liver, brain and abdomen were performed.

Following a 6 hour fast, FDG-PET scanning was performed on a PET-CT scanner one hour after injection of 200 MBq of 18F-FDG. CT scans were performed at 40 mA/120 kV. Contrast-enhanced CT was also conducted at 60 mA/120 kV and images from different modalities were fused by means of computer software.

MRI images were reviewed by two radiologists and PET-CT scans by a radiologist and a nuclear medicine physicist. All reviewers worked independently and were blinded to other imaging results both prior and within the study.

Follow-up to confirm imaging results per patient included mammography (n = 3), breast ultrasound (n = 3), MRI (n =14), PET-CT (n = 12), bone scintigraphy (n = 10), radiographs (n = 9), WB-MRI (n = 6) and abdominal ultrasound (n = 5).
To assess the diagnostic accuracy including sensitivity, specificity, negative and positive predictive values.

Concordance between imaging modalities.
Follow up:
The correlation between modalities in detecting lesions was 87%.

Lymph node:
PET/CT detected 21 lymph node metastases with sensitivity and specificity and accuracy of 96%
WB-MRI detected 16 lymph node metastases with sensitivity of 73%, specificity of 77% and accuracy of 75%.

Distant metastases:
PET/CT demonstrated a sensitivity of 91%, specificity of 86% and accuracy of 90%.
WB-MRI demonstrated a sensitivity of 95%, specificity of 92% and accuracy of 94%.

WB-MRI allowed visualisation of 69 metastases in bone (vs 63 by PET/CT), 70 in the liver (vs 67) and both detected 15 metastases in the lung.

Additional metastases were found using WB-MRI (n = 2 in brain and n = 2 in bone).

FDG-PET/CT efficacy:
Sensitivity = 91% (170/186)
Specificity = 90% (69/77)
Accuracy = 91% (239/263)

WB-MRI efficacy:
Sensitivity = 93% (172/186)
Specificity = 86% (66/77)
Accuracy = 91% (238/263)
General comments:
The authors commented that although the imaging techniques are equally efficient at detecting organ metastases, WB-MRI had a higher diagnostic accuracy and was also superior in respect of showing distant metastases, particularly in abdominal organs, brain and bone.

The confirmatory tests were mainly image based as it was impracticable for the reviewers to obtain histological samples from multiple biopsies.

Despite being a comparative exercise, this was not a proper randomised trial and hence the grade of evidence is lower failing, as it does, to exclude numerous sources of bias.

From: Chapter 2, Presentation and diagnosis

Cover of Advanced Breast Cancer
Advanced Breast Cancer: Diagnosis and Treatment.
NICE Clinical Guidelines, No. 81.
National Collaborating Centre for Cancer (UK).
Copyright © 2009, National Collaborating Centre for Cancer.

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