2014-08-012024-05-13https://scholars.lib.ntu.edu.tw/handle/123456789/645646摘要：乳房磁振造影（Breast MRI）之動態顯影系列（DCE MRI）是一敏感度高（95~100%）但特異度（37~97%）差異大之檢查 1,2。Breast MRI亦可用於評估臨床分級及監測前置化療（NAC）療效 1-5。DCE MRI之半定量及藥理動態學分析可區分患者對 NAC是否有療效 1-6。質子磁振光譜（proton MRS）之膽鹼波峰（choline peak）之分析可增加乳癌診斷之特異度（82~100%），也可用於監測 NAC 療效，因 choline 值之變化和 NAC後之腫瘤大小相關（r=0.91, P =0.01），且 choline 之變化可能在第一次化療後 24小時便偵測出 3,7-22。 乳房葡萄糖正子造影（FDG PET）亦曾被用來評估乳癌臨床分級及監測 NAC療效，且 FDG uptake 之變化比腫瘤大小之變化更敏感 23-43。但 FDG PET 在原發性乳癌本身及腦部、腋下淋巴結之評估較不敏感 30,44。 文獻上已有一些結合 FDG PET/CT 和 Breast MRI於乳癌診斷及監測 NAC 療效之研究 6,12,22,36,45。靜態 PET 之標準吸收值（SUV）、MRI診斷參數和乳癌分子標記（動情激素及黃體素接受體、人體上皮生長因子接受體-2）之狀態相關，故這些診斷參數可反映臨床預後 34,37,46-50。MRS choline 值在 NAC 療程之變化和 SUV最大值之變化高度相關（r=0.84, P=0.02）22。動態 PET參數在 NAC 療程之變化亦和 DCE MRI診斷參數相關，且皆可反映 NAC 之療程變化 6。然而，PET/CT 和MRI是在不同時間以不同機器檢查，故有時乳房病灶之比對會因擺位不盡相同而產生困難。且在選擇 PET 及MRS , DCE MRI之分析區域（ROI/VOI）時，會有主觀選擇之偏差。PET/MR（正子暨磁振造影）可解決此問題。PET/MR 比 PET/CT 輻射劑量低，且更能提供軟組織分析之資訊，且最新之 PET/MR 機種─整合式（integrated）PET/MR，可使病人同時接受全身PET 及MRI，及特定部位（原發腫瘤部位）之 PET 及 MRI，所以不會有不同時間受檢以致擺位不同之情形 51-55。而我們可依 PET 之 SUV最大值(SUVmax)區域來選擇MRS及 DCE MRI預分析之 ROI/VOI，故各組之分析區域皆會一致。PET/MR 和 PET/CT 對原發腫瘤之準確度相當，但 PET/MR 比 PET/CT 之分級更敏感，因而更可能改變臨床治療方針 53,56。然而，PET/MR 在乳癌之應用並不常提及 53,56,57。 我們將以整合式 PET/MR 從事下列研究： 1. 以 PET 導引之 proton MRS及 DCE MRI分析監測乳癌 NAC 療效。 2. 以動態及靜態 PET 來監測 NAC療效，並探究是否 PET 參數和 MRS, DCE MRI之參數相關。 3. 比較 PET/MR 和臨床評估之分級結果。 4. 在化療前之 PET/MR，將分析 PET 及 MRI各診斷參數是否和乳癌分子標記相關。 <br> Abstract: Breast MRI with dynamic contrast-enhanced series (DCE MRI) is sensitive for breast cancer diagnosis (sensitivity 95-100%) with variable specificity (37-97%)1-2. Breast MRI was also used for pre-operative staging, and monitoring of therapeutic response of neoadjuvant chemotherapy (NAC)1-5. DCE MRI analysis with semi-quantitative and pharmacokinetic method can discriminate the responders versus non-responders during NAC1-6. Analysis of choline peak on proton MR spectroscopy (MRS) can increase the MRI specificity of breast lesion diagnosis to 82-100%3,7-13. Choline analysis was also used for monitoring treatment response of NAC14,15. The change of choline integral can parallel the response status of NAC and was well correlated (r=0.91; P=0.01) with the change of lesion size, and the choline change can be found at 24 hours after first dose of chemotherapy16-22. Breast Positron Emission Tomography (PET) with 18F-FDG (2-deoxy-2-(18F)fluoro-D-glucose) was mainly used for staging and monitoring of treatment response of NAC, with the reduction of FDG uptake (P<0.001) was more evident than that of tumor size (P=0.005)23-43. However, FDG PET displayed a limited role in evaluation of primary breast cancer, brain and axillary lymph nodes metastases30,44. There were publications regarding combined FDG PET/CT and breast MRI for breast cancer diagnosis and monitoring NAC response6,12,22,36,45. The SUV on static PET and MRI findings were correlated well with molecular marker status of breast cancer (ER, PR, HER2), and were associated with clinical outcome34,37,46-50. The change of choline integral on MRS was well correlated to the peak of SUV during NAC (r=0.84,P=0.02)22.The changes of dynamic PET parameters including rate constants for uptake, washout and FDG influx were moderately correlated with the DCE MRI parameters and can reflect the response status of NAC6. However, PET/CT and MRI were performed by two machines at different time, so breast positioning is different, causing the lesion targeting sometimes difficult. Moreover, the selection of ROI/VOI for PET and MRS, DCE MRI is subjective with inter-observer bias. A new technology- PET/MR- can solve these problems. PET/MR has less radiation and offers more soft tissue details than PET/CT. A most recent PET/MR design- integrated PET/MR- is commercially available. Using the integrated PET/MR, patients can undergo whole body PET and MRI at the same time, followed by dedicated protocol for specific organ of primary tumor origin51-55. The ROI/VOI of breast DCE MRI, MRS can be selected according to SUVmax site from PET, which is more objective and can ensure that the VOI/ROI is at same location across all techniques. PET/MR showed comparable reliability to PET/CT for detection of oncologic diseases, and contributed even more changes of clinical management than PET/CT53,56. However, use of PET/MR for breast cancer was seldom reported53,56-57. We will use integrated PET/MR for the studies below: 1. Use of PET-guided proton MRS and DCE MRI for patients who will receive NAC for breast cancer to monitor treatment response. 2. Use of dynamic and static PET to monitor treatment response for NAC, and to investigate the correlation of PET results versus MRS, DCE MRI. 3. Compare clinical staging by of PET/MR with clinical assessment. 4. On pre-chemotherapy studies, to investigate the association of molecular marker status with the dynamic and static PET, SUV, MRS and DCE MRI parameters.整合式正子暨磁振造影乳房腫瘤正子造影質子磁振光譜(Proton MRS)動態顯影磁振造影(DCE MRI)Integrated PET/MRBreast neoplasmsPETproton MR spectroscopydynamic contrast-enhanced MRI (DCE MRI).