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The Role of FDG PET/CT in Detection of Distant Metastasis in the Initial Staging of Breast Cancer

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The Role of FDG PET/CT in Detection of Distant Metastasis in the Initial Staging of Breast Cancer Turkish Journal of Medical Sciences Turk J Med Sci (2016) 46: 349-360 http://journals.tubitak.gov.tr/medical/ © TÜBİTAK Research Article doi:10.3906/sag-1409-1 The role of FDG PET/CT in detection of distant metastasis in the initial staging of breast cancer 1 1 1 1 1 Anar ALIYEV , Sabire YILMAZ AKSOY , Meftune ÖZHAN , Özgül EKMEKÇİOĞLU , Betül VATANKULU , 2 1 3 1 1, Pınar Çiğdem KOCAEL , Muhammet Sait SAĞER , Melih Engin ERKAN , Kerim SÖNMEZOĞLU , Metin HALAÇ * 1 Department of Nuclear Medicine, Cerrahpaşa Faculty of Medicine, İstanbul University, İstanbul, Turkey 2 Department of General Surgery, Cerrahpaşa Faculty of Medicine, İstanbul University, İstanbul, Turkey 3 Department of Nuclear Medicine, Faculty of Medicine, Düzce University, Düzce, Turkey Received: 02.09.2014 Accepted/Published Online: 30.06.2015 Final Version: 17.02.2016 Background/aim: We aimed to evaluate the role of FDG PET/CT in the detection of extraaxillary regional nodal/distant metastasis in breast cancer patients and to assess the value of FDG PET/CT for detecting distant metastases in patient subgroups. Materials and methods: A total of 254 patients with breast cancer (248 female, 6 male) who underwent PET/CT for initial staging were enrolled. Patients were divided into four groups: Group 1 consisted of 154 patients diagnosed by tru-cut/core/FNAB, Group 2 comprised 32 patients diagnosed by excisional biopsy, Group 3 included 62 patients who had mastectomy-axillary lymph node dissection, and Group 4 consisted of 6 patients who had axillary lymph node metastasis diagnosed by excisional biopsy. Results: PET/CT detected distant metastasis in 76 of the 254 patients. Of these patients, 21.7% had bone/bone marrow metastasis, 7.1% had lung metastasis, 13% had mediastinal lymph node metastasis, 4.8% had liver metastasis, 9.8% had other organ/system metastasis, and 6% had other lymphadenopathies. According to T staging, the percentages of distant metastasis were as follows: 13.6% of the 66 T1 stage patients, 35.7% of the 129 T2 stage patients, 40% of the 20 T3 stage patients, and 33.3% of the 39 T4 stage patients. Conclusion: FDG-PET/CT led to a change in the stage of disease and the treatment approach in newly diagnosed breast cancer patients due to its superiority in detecting extraaxillary regional lymph node metastases and distant metastases. Key words: FDG PET/CT, breast cancer, distant metastasis 1. Introduction and chemotherapy. The main goal of surgical treatment Breast cancer is the most common type of cancer in is the optimal control of tumor in the breast and axilla. women and the second leading cause of death by cancer Systemic chemotherapy and hormonotherapy aim to treat among women (1). The 5-year survival rate is about 80% possible undetermined micrometastases. The treatment in local breast cancer, whereas it is 25% in metastatic breast modalities for the disease when it is limited to the breast cancer; the presence of distant metastases is the most and the regional lymph nodes are usually surgery, adjuvant important prognostic factor in breast cancer (2). Hence, chemotherapy, and hormonotherapy. For metastatic accurate initial staging is the most important indicator in cases, however, less aggressive palliative treatments are choosing a treatment modality in breast cancer. The risk of preferred. The primary treatment is chemotherapy, and in developing breast cancer (0–110 age) is 7%–10% in women some instances RT in cases of distant metastatic disease. during their lifetime and approximately one in every 10 to Such patients rarely require surgical treatment (simple 14 women develops breast cancer. Male breast carcinoma mastectomy, metastasectomy, etc.). constitutes about 1% of all breast cancers (3). Breast cancer Ultrasonography (US), mammography, and magnetic is a rare disease under the age of 25. The risk of breast cancer resonance imaging (MRI) are the standard imaging increases as a woman gets older. Most breast cancers occur techniques in the diagnosis of breast cancer. However, between the ages of 45 and 75 years (4). these modalities provide anatomical information rather The choice of a treatment modality in early invasive than information on metabolic activity, which is correlated breast cancer involves a multidisciplinary approach with prognosis. Additionally, these methods cannot show including the combination of surgery, radiotherapy (RT), extraaxillary regional lymph node metastases and distant * Correspondence: [email protected] 349 ALIYEV et al. / Turk J Med Sci metastases. Locally advanced breast cancer has a poor compared with those about conventional imaging methods prognosis because of its high rate of distant metastases (including CT). It was suggested that PET/CT is an (5). The National Comprehensive Cancer Network effective imaging modality in detecting occult metastases recommends the use of chest radiography (CXR), in breast cancer. One study with a limited number of mammography, and breast US as necessary, and optional patients showed that PET/CT can determine occult additional studies as indicated by symptoms such as metastases in 10% of patients with stage 2–3 breast cancer breast MRI, skeletal scintigraphy, computed tomography (12). In a recent study examining the detection of distant (CT), US, or MRI of the abdomen; CT, US, or MRI of metastases in breast cancer by PET/CT, the sensitivity and the pelvis; and 18F-fluorodeoxyglucose (FDG) positron specificity were 97.4% and 91.2%, respectively, while by emission tomography (PET)/CT scan for staging of locally the conventional imaging methods they were 85.9% and advanced breast cancer at the time of diagnosis. CT and 67.3%, respectively (13). Although the role of PET/CT in MRI can be helpful for clarification of suspected cases the initial staging of breast cancer and the routine usage of (6). Despite negative findings with conventional imaging PET/CT is controversial, we thought that PET/CT can be methods, some patients present with distant metastases a cost-effective on the basis of these data. short time later. Thus, the role of aggressive local treatment Here, we performed a retrospective study to identify is controversial in this group of patients. More advanced the role of FDG PET/CT in detecting extraaxillary imaging methods are needed for the detection of possible regional lymph nodes and distant metastases in patients distant metastases in order to prevent ineffective aggressive with breast cancer who were referred to our department local treatment. Early detection of distant metastases and for FDG PET/CT. their proper management provide both better prognosis and a reduction in unnecessary procedures. 2. Materials and methods Malignant tumors have increased glucose metabolism and PET/CT using FDG can detect these lesions effectively 2.1. Patient group (7). FDG PET/CT, which provides both anatomical Between May 2005 and June 2011, a total of 254 patients and functional information, allows diagnosis, staging, (248 women, 6 men, mean age: 54.3 ± 13.8) with breast evaluation of response to therapy, and detection of cancer who underwent PET/CT for initial staging were recurrences in many types of cancer (7,8). FDG PET has included in this study. These patients were composed been used for the detection of primary tumors, lymph of four separate groups: 154 patients with breast cancer node metastases, and distant metastases in breast cancer diagnosed by tru-cut/core or FNAB (Group 1), 32 patients and it is superior to conventional imaging methods in diagnosed by excisional biopsy (Group 2), 62 patients the detection of distant metastases (9–11). FDG PET who had mastectomy and axillary lymph node dissection has a sensitivity, specificity, and accuracy of 87%, 83%, (Group 3), and 6 patients who had axillary lymph node and 87%, respectively, in detecting distant metastases in metastasis diagnosed by excisional biopsy (Group 4). breast cancer. Combined conventional imaging methods Of these patients, 203 had invasive ductal carcinoma, 13 include CXR, US of the abdomen and the axilla, and had invasive lobular carcinoma, 6 had invasive mucinous bone scintigraphy and plain-film X-rays of the bones, if cancers, 15 had invasive ductal/lobular cancers, and 17 necessary, which have a sensitivity and specificity of 43% had other than these histopathological results. A total of and 98%, respectively. Sensitivity, specificity, and accuracy 129 patients had right breast cancer, 119 had left breast of CT in detecting distant metastases in breast cancer were cancer, and 6 patients had bilateral breast cancer. In terms reported to be 83%, 85%, and 84%, respectively (11). of disease stage, 66 had T1 stage disease, 129 had T2 stage There is a limited number of studies concerning the disease, 20 had T3 stage disease, and 39 had T4 stage role of FDG PET/CT in the staging of breast cancer when disease (Table 1). Table 1. Patient groups and T stages. Patients groups Group 1 Group 2 Group 3 Group 4 Total (n) T1 29 12 22 3 66 T2 81 13 34 1 129 T stage T3 14 3 2 1 20 T4 30 4 4 1 39 Total (n) 154 32 62 6 254 350 ALIYEV et al. / Turk J Med Sci Of the 6 male patients (mean age: 63.3 ± 14.0), 5 patients background physiological activity was considered to be were diagnosed by tru-cut/core or fine needle aspiration significant. (FNA) biopsy and 1 patient was diagnosed by mastectomy On FDG PET/CT imaging, FDG-positive lesions and axillary dissection. All 6 patients had invasive ductal were categorized as extraaxillary regional lymph nodes carcinoma; 2 of them were in the right breast and 4 were metastases (ipsilateral suprainfraclavicular–internal in the left breast. One of the 6 patients was stage T1, 3 were mammary lymphadenopathies) and distant metastases. T2, and 2 were T4. Distant metastases were classified as contralateral axillary– In Group 1, of the 154 patients with breast cancer supraclavicular–internal mammary lymphadenopathies, diagnosed by tru-cut or FNA biopsy, 127 patients had bone lesions, lung lesions, mediastinal lymphadenopathies invasive ductal cancer, 7 had invasive lobular cancer, 5 (LAPs), liver lesions, and other lesions.
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