True Positive MRI & PEM

2. PEM True Negative …The Power of Specificity False Positive MRI True Negative PEM PEM LCC True Positive MRI & PEM PEM RCC History: 44 y/o female with bilateral breast implants. Finding: MRI found Bilateral masses suspicious for malignancy seen. PEM found R irregular mass suspicious for malignancy, left breast normal. Pathology: R breast IDC; L breast benign fibrocystic change. PEM RMLO PEM LMLO Images courtesy James Rogers, MD, Swedish Medical Center, Seattle, WA

3. Comparison to Breast MRI …Imaging a Suspicious Mass R L L R False positive nodule Cancer MRI PEM • Findings: • Recommended biopsy of suspicious • lesion in left breast---found to be benign • Findings: • PEM …no suspicious findings in left breast • 13 mm irregular mass of FDG uptake in • right breast found to be cancer Pathology confirmed that PEM was correct Schilling: High Resolution PEM: Utility in Pre-Surgical Planning for Breast Cancer Patients. SNM Meeting 2008

4. Pathological Confirmation of Two IDC Lesions Left Breast: MRI and PEM found 2 IDC lesions not seen by mammography. Ultrasound identified lesion at 10 o’clock. MRI acquired at 0.6 mm slice thickness. PEM showed closer estimate of lesion size. PEM interpretation time was significantly faster than MRI. Pathology Images courtesy James Rogers, MD, Swedish Cancer Institute, Seattle, WA MRI PEM Pathology

5. Pre-surgical Planning Right breast with 10 mm round mass in lower, outer quadrant, 8.2 cm from nipple. Lesion PUVmax is 6.6; Bkg PUVmean is 0.3; LTB ratio is 22. Assessment: BIRADS 5, highly suggestive of malignancy. Pathology: IDC grade III. CC Slice 10 8.2 cm

6. PEM for Pre-surgical Planning Right Breast Left Breast 40 y/o female with area of increased density in the left inferior breast. Ultrasound biopsy found IDC and MRI confirmed single index cancer in left breast Cancer not seen with Mammography Ultrasound or MRI Mammogram (X-ray – Anatomic Imaging) • …However, PEM found bilateral cancer: • Left index cancer plus 2 small satellite cancers • Right cancer - hidden in the upper outer quadrant Additional cancer lesions PEM (Molecular Imaging)

7. Neoadjuvant Chemotherapy Monitoring Day 0 Day 7 Day 14 PEM CC PEM can detect whether therapies are having an effect on patients EARLY…within the first cycle of treatment! PEM is indicated as a biomarker to gauge progression of disease. PEM MLO Images courtesy of Mary K. Hayes, MD, Memorial Healthcare System, Hollywood, FL

8. Lymph Node/Axilla Evaluation Invasive ductal carcinoma at 2:00 o’clock right breast. Level I lymph node seen, and suspicious for metastatic disease. Axillary imaging shows numerous lymph nodes with FDG uptake consistent with metastatic disease. Seven of 7 nodes were positive for cancer.

9. Hormone Effect on MRI and PEM History: 49 year old pre-menopausal woman with dense breasts recently diagnosed with invasive cancer on the left breast. Findings: MRI shows severe bilateral enhancement due to hormone effect and considered non-diagnostic for additional disease. PEM correlates index lesion. Axilla shows metastatic disease to the lymph nodes. No hormone effect with PEM. Images courtesy Kathy Schilling, MD, Boca Raton Regional Hospital, Boca Raton, FL

10. PEM Axillary Tail Imaging Right breast FDG uptake in known multifocal IDCLeft FDG uptake in axillary tail matches MRI finding….but Images courtesy James Rogers, MD, Swedish Cancer Institute, Seattle, WA

11. Delayed PEM Imaging 138 min post injection 158 min post injection Delayed PEM imaging showed loss of FDG uptake consistent with it being a benign process. Biopsy showed chronic inflammatory cells, periductal & perilobular. Images courtesy James Rogers, MD, Swedish Cancer Institute, Seattle, WA

12. PEM for Recurrent Cancer 73 y/o with history of left papillary cancer treated with lumpectomy 12 yrs ago.Presented with abnormal right mammogram, biopsy found IDC.PEM for pre-surgical planning confirms index cancer in right breast and finds recurrent papillary cancer in left breast (both path proven). Recurrent Papillary Cancer New IDC Left Right Images courtesy of Kathy Schilling, MD, Boca Raton Regional Hospital, Boca Raton, FL

13. Appropriate Patient Re-Staging with PEM RMLO Mammogram RMLO PEM History: 63 year-old woman with DCIS in left breast identified on mammogram with no apparent disease in contralateral breast. Pathology of left breast showed Stage 0 disease. Patient underwent PEM for staging. Findings: PEM found 1.9 cm IDC in the left breast not initially seen on routine imaging. Patient was re-staged as Stage 1 and Oncotype DX assay results determined tumor to be aggressive. Without PEM she would not have had necessary chemotherapy regimen and lesion would have remained undetected in her breast. Images courtesy of Michael Kinney, MD, The Center for Advanced Breast Care, Arlington Heights, IL

14. PET-Guided Biopsy (Naviscan Exclusive Feature) Target Validate Sample The Only FDA-Cleared, CE Mark Approved, Commercially-Available PET-Guided Biopsy Confirm

15. Utilization of PEM …beyond Breast Note the anatomical detail in the PEM image showing the photopenic center from the dead cancer with only mild post-radiation inflammation. PEM Scan X-ray WBPET