Initial Staging Of Breast Cancer Research Articles

Assessment of whole-body MRI including diffusion-weighted sequences in the initial staging of breast cancer patients at high risk of metastases in comparison with PET-CT: a prospective cohort study.

The aim of this study was to assess the diffusion-weighted whole-body-MRI (WBMRI) in the initial staging of breast cancer at high risk of metastases in comparison with positron emission tomography (PET)-CT. Forty-five women were prospectively enrolled. The inclusion criteria were female gender, age >18, invasive breast cancer, an initial PET-CT, and a performance status of 0-2. The exclusion criteria were contraindication to WB-MRI and breast cancer recurrence. The primary outcome was the concordance of WB-MRI and PET-CT in the diagnosis of distant metastases, whereas secondary outcomes included their concordance for the primary tumor and regional lymph nodes (LN), as well as the agreement of WB-MRI interpretation between two radiologists. The mean age was 51.2 years with a median size of the primary tumor of 30 mm. Concordance between the two modalities was almost perfect for metastases staging, all sites included (k= 0.862), with excellent interobserver agreement. The accuracy of WB-MRI for detecting regional LN, distant LN, lung, liver, or bone metastases ranged from 91 to 96%. In 2 patients, WB-MRI detected bone metastases that were overlooked by PET-CT. WB-MRI showed a substantial agreement with PET-CT for staging the primary tumor, regional LN status, and stage (k= 0.766, k= 0.756, and k= 0.785, respectively) with a high interobserver agreement. WB-MRI including DWI could be a reliable and reproducible examination in the initial staging of breast cancer patients at high risk of metastases, especially for bone metastases and therefore could be used as a surrogate to PET-CT. Whole-body-MRI including DWI is a promising technique for detecting metastases in the initial staging of breast cancer at high risk of metastases. Whole-body-MRI (WB-MRI) was effective for detecting metastases in the initial staging of 45 breast cancer patients at high risk of metastases in comparison with PET-CT. Concordance between WB-MRI and PET-CT was almost perfect for metastases staging, all sites included, with excellent interobserver agreement. The accuracy of WB-MRI for detecting bone metastases was 92%.

Disparities in minority patients with breast cancer under 40 years of age: A single center experience.

e18553 Background: Current guidelines recommend screening for breast cancer (BC) starting at age 40. However, BC in women under 40 years is increasing in incidence. Pathogenic germline mutations are found to be the driving force in nearly 17% of those diagnosed under 45 years and 50% of those under 30 years. Limited data is available on the prevalence of pathogenic mutations in minority patients. We conducted a retrospective analysis of young breast cancer patients from low socioeconomic backgrounds between 2010-2022 at a single center in Central Texas. Methods: Patients were selected based on a diagnosis of BC under 40 years old and living at or below 200% of federal poverty level as noted through their insurance status of Medicaid and Medical Assistance Program of Travis County. Data regarding age of diagnosis, demographics, clinical presentation, staging, germline mutations and outcomes were extracted from the medical record. Descriptive statistics were used to analyze the dataset. Results: A total of 125 patients were identified for the study. Median age of the cohort was 35 years old (range: 19-39 years). Demographics included 61 Hispanic patients (48.8%), 40 White patients (32.0%), 16 Black patients (12.8%) and < 2% for each other group. Analysis of germline mutations was available for 86 patients. High risk mutations were identified in 28 patients, including 13 Caucasian women, 10 Hispanic women, and three Black women. BRCA mutations were the most common mutation (75%). Other mutations included CHEK2 (7.2%), MUTYH (7.2%), ATM (3.6%), PIK3CA (3.6%), PTEN (3.6%), RAD51C (3.6%) and RAD51D (3.6%). Variants of unknown significance were found in 18 patients, including 11 Hispanic women, four Black women and two White women. Forty patients had BC independent of mutations. Staging on initial diagnosis was available for 113 patients, 40.7% of which were locally advanced (28.3% in Stage III disease and 12.4% with metastatic disease). Advanced disease was higher in Hispanic patients (22/61) and Black patients (10/16) compared to White patients (10/40). Breast cancer subtypes included 22.8% with triple negative BC, 8.1% with HER2-enriched BC, 27.9% with hormone receptor (HR) positive and HER2 negative BC and 14.0% with both HR and HER2 positive BC. At the time of data review, only 30 patients were documented to have died, of which 22 died within five years of diagnosis. Five year death rate was 26.2% for Hispanic patients, 18.8% for Black patients and 7.5% for White patients in the study cohort. Conclusions: This study shows disparities among young Hispanic and Black patients with BC, particularly in the initial staging of BC and 5-year death rate. A large number of VUS were seen in minorities, suggesting little is known about the pathogenic nature of these mutations. Future prospective studies should consider investigating interplay between race and outcomes of those diagnosed with BC under 40 years old.

Prone versus Supine FDG PET/CT in the Staging of Breast Cancer.

Supine [18F]Fluorodeoxyglucose (FDG) positron emission technology/computed tomography (PET/CT) is a commonly used modality for the initial staging of breast cancer, and several previous studies have shown superior sensitivity and specificity of prone FDG PET/CT in comparison to its supine counterpart. This retrospective study included 25 females with breast cancer referred for staging. They underwent supine FDG PET/CT followed by prone FDG PET/CT. The outcomes were: number of primary breast lesions, anatomical site of FDG-avid lymph nodes (LNs), and number and type of bone lesions, with SUVmax of all corresponding parameters. Performance was superior in prone acquisition compared to supine acquisition, with the respective results: 29 vs. 22 breast tumor lesions detected, 62 vs. 27 FDG-avid axillary LNs detected, sensitivity of 68% vs. 57%, specificity of 64% vs. 53%. The detection rate of axillary LNs in the prone position was significantly higher (p = 0.001). SUVmax for breast tumor lesions (p = 0.000) and number of detected axillary LNs (p = 0.002) were significantly higher in prone acquisition. Five patients were upstaged after experts read the prone acquisition. Prone FDG PET/CT acquisition is a promising technique in detecting primary breast lesions and metastatic LNs possibly missed in supine acquisition, which may lead to change in patient staging and management.

Are Diagnostic Computed Tomography Chest Scans Sufficient for Detecting Supraclavicular in Initial Breast Cancer Staging?

<h3>Purpose/Objective(s)</h3> Initial staging workup strategies for locally advanced or suspected stage IV breast cancer can include computed tomography (CT) of the chest, abdomen, pelvis (CAP) and bone scan or, alternatively, a whole-body positron emission tomography/computed tomography (PET/CT). Variations in intravenous contrast injection site and bolus timing, arm positioning, and acquisition techniques on a CT chest scan could limit visualization of supraclavicular (SCV) and supracricoid cervical lymph nodes, which are critical for staging, prognosis, and treatment recommendations. The study's purpose is to determine whether there is a difference between the incidences of SCV and cervical lymphadenopathy detected on staging CT CAP versus PET/CT scans. <h3>Materials/Methods</h3> The records of consecutive newly diagnosed breast cancer patients who received initial staging scans at a single institution from 2012 to 2017 were reviewed in a HIPAA compliant, institutional review board-approved study. De-identified information was reviewed for inclusion: new breast cancer diagnosis, >18 years old, and availability of staging. Exclusion criteria were prior breast cancer treatment, re-staging for known recurrence, and nondiagnostic imaging examinations. Radiology reports were searched for SCV and cervical lymphadenopathy to determine the incidence detected by each imaging modality. A board certified neuroradiologist reviewed and characterized scans that noted cervical or SCV lymphadenopathy. <h3>Results</h3> The initial search resulted in 3,126 PET/CT and 631 CT CAP scans with 588 patients fulfilling the inclusion criteria. PET/CT scans had been performed in 539 patients and 49 received CT CAP and bone scans. The two groups were well matched by stage (Table 1). Metastatic cervical lymphadenopathy was detected by PET-CT in 50 patients (7.9%) versus two (3.7%) with CT CAP. Out of the 50 patients who had cervical lymphadenopathy detected by PET-CT, 30 (60%) had metastatic cervical lymphadenopathy above the level of the lung apex, the typical upper extent of a CT chest field of view. Although 25 (50%) patients had additional areas of distant metastatic disease, cervical lymphadenopathy above the thoracic inlet was the only site of distant metastasis for 13 patients (26%), and would not have been detectable by CT CAP. <h3>Conclusion</h3> PET/CT detected more cervical and SCV lymphadenopathy than CT CAP in initial staging scans for breast cancer, with 60% of those detected on PET/CTs in areas that would have been occult on standard CT chest scans. Such nodal involvement constituted the only site of distant metastatic disease in 26% of the patients. Thus, dedicated CT neck imaging may be a reasonable addition to CT CAP as an initial staging strategy to determine accurate staging and radiation treatment field volumes and borders.

Investigation of Added Value of Imaging Performed in a Prone Position to Standard 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging for Staging in Patients with Breast Cancer.

Objectives:To investigate whether additional imaging in a prone position has any value to the supine whole-body 18fluorine-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) images by comparing the visual and quantitative data about a local disease in the breast and axilla for the initial staging of breast cancer (BC).Methods:In this study, a total of 91 female patients with the BC were studied. Both the supine and prone images were examined based on the axial diameter, number and location of the primary tumor, local invasion signs of the tumor, the number of axillary lymph nodes with a suspected metastasis, metabolic parameters of the primary tumor and axillary lymph nodes, and registration artifacts of the PET and CT images were evaluated individually. These findings were compared with the histopathological data obtained after a surgery.Results:In the evaluation of a supine and prone imaging, tumor diameter and metabolic tumor volume (MTV) values of the breast lesions were greater in the supine position than in the prone position. However, there was no significant difference found between the other metabolic parameters of a primary tumor and axilla in both positions. In the supine and prone images, accuracy for skin involvement was 84% and 91.3%, respectively.Conclusion:In our study, we observed that, obtaining additional images in the prone position does not significantly benefit the evaluation of a local disease. The average values of the primary tumor diameter and MTV in the prone position appear to be smaller than the one in the supine position. However, the prone imaging in the patients with a newly diagnosed BC may be beneficial in selected patients and may contribute to preventing the false-positive results especially in patients with a suspected skin involvement.

Breast cancer: initial workup and staging with FDG PET/CT.

PurposePrecise staging is needed to plan optimal management in breast cancer. 18F-fluorodeoxyglucose positron emission tomography coupled with computed tomography (FDG-PET/CT) offers high sensitivity in detecting extra axillary lymph nodes and distant metastases. This review aims to clarify in which groups of patients staging with FDG-PET/CT would be beneficial and should be offered. We also discuss how tumor biology and breast cancer subtypes should be taken into account when interpreting FDG-PET/CT scans.MethodsWe performed a comprehensive literature review and rigorous appraisal of research studies assessing indications for FDG-PET/CT in breast cancer. This assessment regarding breast cancer served as a basis for the recommendations set by a working group of the French Society of Nuclear Medicine, in collaboration with oncological societies, for developing good clinical practice recommendations on the use of FDG-PET/CT in oncology.ResultsFDG-PET/CT is useful for initial staging of breast cancer, independently of tumor phenotype (triple negative, luminal or HER2 +) and regardless of tumor grade. Considering histological subtype, FDG-PET/CT performs better for staging invasive ductal carcinoma, although it is also helpful for staging invasive lobular carcinomas. Based on the available data, FDG-PET/CT becomes useful for staging starting from clinical stage IIB. FDG-PET/CT is possibly useful in patients with clinical stage IIA (T1N1 or T2N0), but there is not enough strong data to recommend routine use in this subgroup. For clinical stage I (T1N0) patients, staging with FDG-PET/CT offers no added value.ConclusionFDG-PET/CT is useful for staging patients with breast cancer, starting from clinical stage IIB.

Impact of 18F-FDG PET, PET/CT, and PET/MRI on Staging and Management as an Initial Staging Modality in Breast Cancer: A Systematic Review and Meta-analysis.

We performed a systematic review and meta-analysis to evaluate the impact of 18F-FDG PET, PET/CT, and PET/MRI on staging and management during the initial staging of breast cancer. We searched the PubMed, Embase, Cochrane Library, and KoreaMed databases until March 2020 to identify studies that reported the proportion of breast cancer patients whose clinical stage or management were changed after PET scans. The proportion of changes was pooled using a random-effects model. Subgroup and metaregression analyses were performed to explore heterogeneity. We included 29 studies (4276 patients). The pooled proportions of changes in stage and management were 25% (95% confidence interval [CI], 21%-30%) and 18% (95% CI, 14%-23%), respectively. When stage changes were stratified according to initial stage, the pooled proportions were 11% (95% CI, 3%-22%) in stage I, 20% (95% CI, 16%-24%) in stage II, and 34% (95% CI, 27%-42%) in stage III. The relative proportions of intermodality and intention-to-treat changes were 74% and 70%, respectively. Using metaregression analyses, the mean age and the proportion of initial stage III to IV and histologic grade II to III were significant factors affecting the heterogeneity in changes in stage or management. Currently available literature suggests that the use of 18F-FDG PET, PET/CT, or PET/MRI leads to significant modification of staging and treatment in newly diagnosed breast cancer patients. Therefore, there may be a role for routine clinical use of PET imaging for the initial staging of breast cancer.

The Value of 18 Fluorine-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Imaging in Breast Cancer Staging

BACKGROUND: Accurate staging is important for management decisions in patients with newly diagnosed breast cancer.&#x0D; AIM: This study was conducted to evaluate the value of 18 fluorine-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) imaging in breast cancer staging..&#x0D; METHODS: A prospective study of 80 patients (1 male and 79 female) mean age 51.13 years with histologically confirmed breast cancer. The staging procedures included history, physical examination, mammography, and CT of neck, chest, abdomen, and pelvis; then, PET/CT was performed in a time interval &lt;30 days. The findings of PET/CT were compared with those of the other conventional methods.&#x0D; RESULTS: The agreement between conventional methods (mammography, breast ultrasound, contrast-enhanced CT of the neck, chest, abdomen, and pelvis) and 18F FDG-PET/CT was 0.6 for assessing the T stage, 0.39 for N stage, and 0.75 for M stage. There was moderate agreement between CT and 18F FDG-PET/CT in the detection of nodal lesions (K=0.6) and pulmonary lesions (K=0.51), while a perfect agreement was noted for detecting osseous (K=0.82) and liver lesions (K=0.81). In total, 50 patients (62.5%) were concordantly staged between the conventional imaging and 18F-FDG PET/CT, while 30 patients (37.5%) showed a different tumor, node, and metastasis stage. The changes were driven by the detection of additional findings (n=26) or exclusion of findings (n=4), mainly at the lymph nodes (LNs) and/or distant sites. Regarding N status, 18F FDG-PET/CT revealed previously unknown regional lymphatic spread in supraclavicular (n=4; 5%), infraclavicular (n=11; 13.7%), and internal mammary (n=12; 15%) lymph node groups. 18F-FDG PET/CT changed M status in a total of four patients (5%); three of them were upstaged by detecting distant metastases, while osseous deposits were excluded in one patient leading to downstaging.&#x0D; CONCLUSION: 18F-FDG-PET/CT is considered a valuable imaging tool in the initial staging of breast cancer, which significantly impacts the overall American Joint Committee on Cancer staging in 37.5% of our study population.

Parámetros de la 18F-FDG PET/CT asociado con los factores pronósticos en la estadificación inicial del Cáncer de Mama

Propósito de la revisión: Este artículo tiene la siguiente pregunta de investigación: ¿Se debe considerar la Biología, histología y el fenotipo para la estadificación inicial del Cáncer de Mama? Se realiza una revisión del estudio metabólico del cáncer de mama (CM) con la técnica de la captación de glucosa Fluorada 18-Fluoro-2-Desoxi-D-Glucosa y su medición de intensidad con tomografía por Emisión de positrones (18F-FDG PET/CT).&#x0D; Recientes Hallazgos: La 18F-FDG PET/CT puede detectar metástasis que no son visibles en otras modalidades, el carcinoma ductal invasivo muestra una mayor captación que el carcinoma lobular invasivo. La alta captación de 18F-FDG se ha asociado con un resultado peor y una supervivencia más corta.&#x0D; Extracto: El cáncer de mama es un tipo heterogéneo de malignidad porque varios factores afectan su comportamiento y pronóstico. Debido a esta heterogeneidad, el tratamiento óptimo y la respuesta esperada al tratamiento puede variar sustancialmente para cada paciente. 18F-FDG PET/CT puede proporcionar información relevante sobre el metabolismo, el diagnóstico y el pronóstico del cáncer de mama. Varios estudios han sugerido una correlación entre las características clínico-patológicas del cáncer de mama y los parámetros metabólicos obtenidos por 18F-FDG PET/CT.

Assessment of biological and clinical aggressiveness of invasive ductal breast cancer using baseline 18F-FDG PET/CT-derived volumetric parameters

The aim of this study was to evaluate the relationship of baseline fluorine-18-fluorodeoxyglucose PET/computed tomography (CT)-derived volumetric parameters for the primary tumor with clinicopathological risk factors and molecular subtypes in patients with invasive ductal breast carcinoma (IDBC). We evaluated 65 patients who underwent fluorine-18-fluorodeoxyglucose PET/CT for initial breast cancer staging. The association of maximum and mean standardized uptake values (SUVmax and SUVmean, respectively), metabolic tumor volume, and total lesion glycolysis (TLG) with clinicopathological risk factors and molecular subtypes was investigated and the discriminative power of significant features was assessed. All volumetric parameters were significantly higher for tumors measuring more than 2 cm and with a Ki-67 index of at least 20. Estrogen receptor (ER) and progesterone receptor (PR)-negative (ER-/PR-), human epidermal growth factor receptor 2-positive (HER2+), and triple-negative tumors showed increased SUVmax. SUVmax and SUVmean were higher for triple-negative and HER2+ IDBC than for ER+/HER2- IDBC. Metabolic tumor volume and TLG showed no differences among subtypes. All volumetric parameters correlated with the clinical tumor size and the Ki-67 index; these correlations differed among the different subtypes. Patients with systemic metastases showed significantly higher TLG. Receiver operating characteristic analysis showed that SUVmax had the highest discriminative power for the different subtypes, whereas TLG had a statistically significant discriminative power for systemic metastasis. SUVmax may appropriately reflect the immunohistochemical characteristics of IDBC, whereas TLG is associated with clinical risk factors and systemic metastasis. Our preliminary findings suggesting different relationships between volumetric parameters and the clinical tumor size and the Ki-67 index for different subtypes require further evaluation.

Ultrasound-Guided Fine-Needle Aspiration of Non-palpable and Suspicious Axillary Lymph Nodes with Subsequent Removal after Tattooing: False-Negative Results and Concordance with Sentinel Lymph Nodes

Ultrasonography-guided fine-needle aspiration (US-guided FNA) for axillary lymph nodes (ALNs) is currently used with various techniques for the initial staging of breast cancer and tagging of ALNs. With the implementation of the tattooing of biopsied ALNs, the rate of false-negative results of US-guided FNA for non-palpable and suspicious ALNs and concordance with sentinel lymph nodes were determined by node-to node analyses. A total of 61 patients with breast cancer had negative results for metastasis on US-guided FNA of their non-palpable and suspicious ALNs. The biopsied ALNs were tattooed with an injection of 1–3 mL Charcotrace (Phebra, Lane Cove West, Australia) ink and removed during sentinel lymph node biopsy or axillary dissection. We determined the rate of false-negative results and concordance with the sentinel lymph nodes by a retrospective review of surgical and pathologic findings. The association of false-negative results with clinical and imaging factors was evaluated using logistic regression. Of the 61 ALNs with negative results for US-guided FNA, 13 (21%) had metastases on final pathology. In 56 of 61 ALNs (92%), tattooed ALNs corresponded to the sentinel lymph nodes. Among the 5 patients (8%) without correspondence, 1 patient (2%) had 2 metastatic ALNs of 1 tattooed node and 1 sentinel lymph node. In multivariate analysis, atypical cells on FNA results (odds ratio = 20.7, p = 0.040) was independently associated with false-negative FNA results. False-negative ALNs after US-guided FNA occur at a rate of 21% and most of the tattooed ALNs showed concordance with sentinel lymph nodes.

Staging performance of whole-body DWI, PET/CT and PET/MRI in invasive ductal carcinoma of the breast.

The aim of the present study was to evaluate the performance of whole-body diffusion-weighted imaging (WB-DWI), whole-body positron emission tomography with computed tomography (WB-PET/CT), and whole-body positron emission tomography with magnetic resonance imaging (WB-PET/MRI) in staging patients with untreated invasive ductal carcinoma of the breast. Fifty-one women with newly diagnosed invasive ductal carcinoma of the breast underwent WB-DWI, WB-PET/CT and WB-PET/MRI before treatment. A radiologist and a nuclear medicine physician reviewed in consensus the images from the three modalities and searched for occurrence, number and location of metastases. Final staging, according to each technique, was compared. Pathology and imaging follow-up were used as the reference. WB-DWI, WB-PET/CT and WB-PET/MRI correctly and concordantly staged 33/51 patients: stageIIA in 7patients, stageIIB in 8patients, stageIIIC in 4 patients and stageIV in 14patients. WB-DWI, WB-PET/CT and WB-PET/MRI incorrectly and concordantly staged 1/51 patient as stageIV instead of IIIA. Discordant staging was reported in 17/51 patients. WB-PET/MRI resulted in improved staging when compared to WB-PET/CT (50 correctly staged on WB-PET/MRI vs.38 correctly staged on WB-PET/CT; McNemar's test; p<0.01). Comparing the performance of WB-PET/MRI and WB-DWI (43 correct) did not reveal a statistically significant difference (McNemar test, p=0.14). WB-PET/MRI is more accurate in the initial staging of breast cancer than WB-DWI and WB-PET/CT, however, the discrepancies between WB-PET/MRI and WB-DWI were not statistically significant. When available, WB-PET/MRI should be considered for staging patient with invasive ductal breast carcinoma.

Rate of Distant Metastases on 18F-FDG PET/CT at Initial Staging of Breast Cancer: Comparison of Women Younger and Older Than 40 Years.

A retrospective single-institution study was performed on women who had breast cancer and no prior malignancy, who were asymptomatic for metastatic lesions on initial clinical examination, and who had initial 18F-FDG PET/CT within 3 mo after pathologic breast cancer diagnosis and before initial treatment. On the basis of these criteria, data for 2 groups of women differing only in age (<40 y and ≥40 y) were extracted from the hospital information system of Curie Institute-Paris. 18F-FDG PET/CT examinations were reviewed, and the DMR was recorded for each clinical stage subgroup (stages I-III). For each group (<40 y and ≥40 y), 107 patients were included, with the same number of patients in each clinical stage subgroup (12 stage I patients, 32 stage IIA patients, 30 stage IIB patients, and 33 stage III patients). The ages of the patients (mean ± SD) were 34.5 ± 4.0 y (<40 y group) and 56.0 ± 10.7 y (≥40 y group). No significant difference in DMRs was observed between the <40 y group and the ≥40 y group (DMRs, 21% and 22%, respectively; P = 1). The DMRs in patients not selected for age were 8% for stage I, 11% for stage IIA, 15% for stage IIB, and 44% for stage III. The DMR was not significantly higher in younger breast cancer patients (<40 y) than in older breast cancer patients (≥40 y), ruling out the assumption that undetected metastases at diagnosis explain the poorer outcome of younger women. However, our results highlight the high yield of 18F-FDG PET/CT for initial breast cancer staging, even in stage II patients, whatever their age.

Sentinel lymph node biopsy in breast cancer: a work in progress.

The sentinel lymph node biopsy is a safe, accurate operation for the initial staging of breast cancer. Over the last decade, there has been increasing literature supporting its use, and it is now considered a standard of care for the initial evaluation of metastatic spread to the axillary lymph node chain.

Should Ultrasound be a Standard Preoperative Tool in Surgical Planning?

Ultrasonography has been used traditionally as an imaging technique for diagnosis and characterization of breast lesions. It has also been increasingly used in the initial staging of breast cancer. Review of the literature suggests that use of ultrasonography, in combination with fine needle aspiration, is an accurate means of staging the axilla, and advances in ultrasound technology have also improved the reliability of results obtained by use of this imaging modality. This review provides an overview of the utility of ultrasonography for assessing patients with breast diseases, with special emphasis on breast cancer and its evolving use in axillary assessment and staging. We also discuss the features of abnormal axillary ultrasound, the accuracy, reliability, and limitations of axillary ultrasound, and finally, the role of axillary ultrasound in the post-ACOSOG Z0011 era.

Role of FDG PET-CT in evaluation of locoregional nodal disease for initial staging of breast cancer.

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is not indicated or recommended in the initial staging of early breast cancer. Although it is valuable for detecting distant metastasis, providing prognostic information, identifying recurrence and evaluating response to chemotherapy, the role of FDG PET/CT in evaluating locoregional nodal status for initial staging of breast cancer has not yet been well-defined in clinical practice. FDG PET/CT has high specificity but compromised sensitivity for identifying axillary nodal disease in breast cancer. Positive axillary FDG PET/CT is a good predictor of axillary disease and correlates well with sentinel lymph node biopsy (SLNB). FDG PET/CT may help to identify patients with high axillary lymph node burden who could then move directly to axillary lymph node dissection (ALND) and would not require the additional step of SLNB. However, FDG PET/CT cannot replace SLNB or ALND due to unsatisfactory sensitivity. The spatial resolution of PET instruments precludes the detection of small nodal metastases. Although there is still disagreement regarding the management of internal mammary node (IMN) disease in breast cancer, it is known that IMN involvement is of prognostic significance, and IMN metastasis has been associated with higher rates of distant metastasis and lower overall survival rates. Limited clinical observations suggested that FDG PET/CT has advantages over conventional modalities in detecting and uncovering occult extra-axillary especially IMN lesions with upstaging the disease and an impact on the adjuvant management.

A study of the usefulness of bone scintigraphy in the initial staging of breast cancer

A study of the usefulness of bone scintigraphy in the initial staging of breast cancer

Whole-body FDG PET/CT is more accurate than conventional imaging for staging primary breast cancer patients

This retrospective study aimed (1) to compare the diagnostic accuracy of whole-body FDG PET/CT for initial breast cancer staging with the accuracy of a conventional, multimodal imaging algorithm, and (2) to assess potential alteration in patient management based on the FDG PET/CT findings. Patients with primary breast cancer (106 women, mean age 57 ± 13 years) underwent whole-body FDG PET/CT and conventional imaging (X-ray mammography, MR mammography, chest plain radiography, bone scintigraphy and breast, axillary and liver ultrasonography). The diagnostic accuracies of FDG PET/CT and a conventional algorithm were compared. Diagnostic accuracy was assessed in terms of primary tumour detection rate, correct assessment of primary lesion focality, T stage and the detection rates for lymph node and distant metastases. Histopathology, imaging or clinical follow-up served as the standards of reference. FDG PET/CT was significantly more accurate for detecting axillary lymph node and distant metastases (p = 0.0125 and p < 0.005, respectively). No significant differences were detected for other parameters. Synchronous tumours or locoregional extraaxillary lymph node or distant metastases were detected in 14 patients (13%) solely by FDG PET/CT. Management of 15 patients (14%) was altered based on the FDG PET/CT findings, including 3 patients with axillary lymph node metastases, 5 patients with extraaxillary lymph node metastases, 4 patients with distant metastases and 3 patients with synchronous malignancies. Full-dose, intravenous contrast-enhanced FDG PET/CT was more accurate than conventional imaging for initial breast cancer staging due to the higher detection rate of metastases and synchronous tumours, although the study had several limitations including a retrospective design, a possible selection bias and a relevant false-positive rate for the detection of axillary lymph node metastases. FDG PET/CT resulted in a change of treatment in a substantial proportion of patients.

P4-16-07: Breast Cancer Bone Metastasis Prevalence and Survival Outcomes: A Quantitative Review of the Literature.

Abstract Background Bone metastases are common in breast cancer patients and an important cause of morbidity and mortality. This review provides the first systematic and quantitative summary of the proportion of breast cancer patients with bone metastasis and their survival, presented by stage at diagnosis and length of follow-up. Materials and methods: A literature review was conducted using PubMed to identify full-text studies published in English 1999–2009. Studies were included if they had ≥100 adult patients with Stage I-IV breast cancer and were generalizable to the overall breast cancer population. The design and intent of included studies varied, including clinical trials of bone-targeted therapies and observational studies of cancer patients evaluating staging techniques, biomarkers, and other factors. To improve homogeneity, studies were grouped by stage at diagnosis, whether follow-up for bone metastases occurred, and the clinical point at which the proportion of patients with bone metastasis was estimated (e.g., at initial staging). Studies reporting survival were only included in quantitative summaries if survival was measured from the date of bone metastasis diagnosis. With regard to clinical trials of bisphosphonates, only proportion and survival data from the placebo group were utilized since the goal was to describe bone metastasis among patients untreated with bone-targeted therapy. Meta-analytic techniques were applied to (1) proportion data using random effects models to calculate weighted averages, and (2) survival data using an average of reported median survivals. Various sensitivity analyses were also conducted. Results: Nineteen studies were included in our quantitative summary of proportion data. At initial staging of breast cancer, 7% (N=2; 95% confidence interval [CI]=5-9%) of all patients had bone metastases and 69% (N=2; 95% CI=47-85%) of Stage IV patients had bone metastases. Among breast cancer patients followed from the diagnosis of Stage I-III breast cancer, 10% (N=6; 95% CI=6-15%) had bone metastases after a median follow-up &amp;lt;10 years, compared to 24% (N=3; 95% CI=19-31%) after a median follow-up ≥10 years. Twelve studies were included in our quantitative summary of survival data. Survival was longer among patients with metastases solely in bone (N=7; average median=30 months), compared to patients with bone metastases and metastases at other sites (N=5; 23 months) and patients with metastases only at sites other than bone (N=3; 9 months). Discussion: Significant heterogeneity across studies was observed, reflecting the variability in study populations, locations, and other factors. Despite this and other limitations (e.g., few studies in some categories), this represents the first analysis of the literature to quantify the prevalence and survival of bone metastasis in breast cancer. Our results indicated that bone is a site of metastasis among more than 50% of Stage IV patients at diagnosis of breast cancer. Median survival among breast cancer patients with metastases located solely in the bone is at least six months longer compared to those with metastases at multiple sites (including bone) and sites other than bone. Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P4-16-07.

The Role of 18F-FDG-Positron Emission Tomography/Computed Tomography in Staging Primary Breast Cancer

Despite Medicare approving the use of positron emission tomography/computed tomography (PET/CT) in staging primary breast cancer, little evidence is available to support the use of (18)F-FDG-PET/CT for the detection of distant metastases in the initial staging of breast cancer. In this review of the literature listed in MEDLINE, we examine whether (18)F-FDG-PET/CT may play a role in the initial staging of breast cancer. We discuss studies comparing PET/CT with conventional imaging for diagnosing distant metastases and axillary and extra-axillary lymph node metastases.