Annals of Oncology Advance Access originally published online on October 16, 2006
Annals of Oncology 2007 18(2):394-395; doi:10.1093/annonc/mdl354
© 2007 European Society for Medical Oncology
letters to the editor |
Role of fluorodeoxyglucose positron emission tomography in the staging of patients with breast cancer candidated to surgery
Medical efforts and financial expenditures devoted to initial breast cancer staging represent a heavy burden on health care resources. Staging the disease accurately is considered to be important before surgery, in order to spare unnecessary treatment to patients with metastatic disease [1]. The role of 2-[fluorine-18]fluoro-2-deoxy-D-glucose–positron emission tomography (FDG-PET) in the staging has been studied recently [2]. Initial results on the role of FDG-PET in addition to the standard work-up of patient with LABC (locally advanced breast cancer) indicated that FDG-PET may contribute to proper stratification between LABC patients and those who are affected by metastatic disease. Preliminary results in a small group of 42 high-risk women with primary or recurrent breast cancer, where FDG-PET and conventional staging methods were compared, FDG-PET revealed additional confirmed lesions in five patients, leading to a significant change in patient management [3]. This, therefore, prompted us to ascertain the relevance of FDG-PET in detecting asymptomatic metastases in the perioperative staging of breast cancer patients. A retrospective review of 228 patients with operable breast cancer staged according to the TNM (tumor–node–metastasis) staging system as T1–3, N0–2 and all referred to the European Institute of Oncology (EIO) during the period from September 2002 to April 2005, was performed. Patients had histologically proven breast cancer, with definitive breast surgery, staging and preoperative PET scan performed at the EIO. PET scan was performed 1–15 days before surgery. Images were obtained 45 min after i.v. injection of 5.3 MBq/kg of [18F]-FDG, using a PET/computed tomography scanner. Stage of disease was defined by standard pathological examinations. All patients had conventional staging (chest X-ray, liver ultrasound and bone scan). Patient characteristics are showed in Table 1. All were asymptomatic at the time of PET scan. The primary tumors were identified in 179 (78%) cases. The positivity rate was different for lobular versus ductal invasive breast cancer patients (60 versus 79%, P = 0.08) and for grade 1 tumors versus grade 2–3 tumors (56% versus 82%, P = 0.003). Thirteen patients (6%) had an uptake at distant sites (bone, four; liver, two; thyroid, two; pleura, one; internal mammary node, one; contralateral breast, one; with two patients having no specific uptake in the lung and abdomen), with standard staging investigations negative. Further examinations confirmed the presence of metastasis in only two cases (Table 2). As shown in Table 2, a magnetic resonance imaging confirmed the presence of multiple bone lesions not detected by bone scan. In this patient multiple uptakes were present at the FDG-PET both in the bone and bone marrow. These results compare favorably with results achieved with bone scan and do not support previously published data, indicating a possible inferiority of FDG-PET in the detection of bone metastases, in particular due to possible missing blastic lesions [4]. In conclusion, our results support a role for PET staging in particular for those patients whose tumors are of high grade and of ductal histology, as previously published [5]. Since baseline PET scans had a cost of
1000 each, which compares with 635.68 of conventional staging costs, the cost-effectiveness for the introduction of PET in the staging of patients with operable breast cancer should be further studied in larger trials.
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1 Research Unit in Medical Senology, Department of Medicine
2 Division of Nuclear Medicine
3 Unit of Quality Control
4 Division of Senology, European Institute of Oncology, Milan, Italy
* E-mail: anna.cardillo{at}ieo.it
References
1. Norum J and Andreassen T. (2000) Screening for metastatic disease in newly diagnosed breast cancer patients. What is cost-effective? Anticancer Res 20:3B2193–2196.[ISI][Medline]
2. Van der Hoeven JJ, Krak NC, Hoekstra OS, et al. (2004) 18F-2-fluoro-2-deoxy-d-glucose positron emission tomography in staging of locally advanced breast cancer. J Clin Oncol 22:71253–1259.
3. Bellon JR, Livingston RB, Eubank WB, et al. (2004) Evaluation of the internal mammary lymph nodes by FDG-PET in locally advanced breast cancer (LABC). Am J Clin Oncol 27:4407–410.[CrossRef][ISI][Medline]
4. Wahl RL. (2001) Current status of PET in breast cancer imaging, staging, and therapy. Semin Roentgenol 36:3250–260.[CrossRef][ISI][Medline]
5. Buck AK, Schirrmeister H, Mattfeldt T, Reske SN. (2004) Biological characterisation of breast cancer by means of PET. Eur J Nucl Med Mol Imaging 31:Suppl 1, 80–87.[CrossRef]
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