© 2007 European Society for Medical Oncology
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Occasional FDG–PET recognition of in situ breast cancer
A 74 years old patient in April 2005 was treated with surgical removal of a skin malignant melanoma localized in the left leg. The deepness of the melanoma was 1.5 cm, with superficial spreading and invasion of the reticular dermis (Clark's level IV, Breslow thickness: 1.5 mm). The tumor–node–metastasis staging was pT2a pNx pMx.After the resection of the melanoma, sentinel lymphadenectomy was carried out in June 2005 and the pathological examination resulted negative for the presence of melanoma. No adjuvant treatment was administered and a standard follow-up program was started. All the follow-up exams resulted negative for local relapse and for metastatic spreading until November 2006 when a 2-[fluorine-18]fluoro-2-deoxy-D-glucose Positron emission tomography (FDG–PET) identified an area of intense pathologic metabolism in the left breast near to the nipple (Figure 1).
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Standard X-ray mammography and breast ultrasonography, carried out after the FDG–PET, were completely negative.
As a consequence, breast magnetic resonance imaging (MRI) was carried out. This last investigation showed a 22 mm spot in the left nipple region, with irregular margins (that indicated a malignant formation) and bilateral axillary lymph nodes.
A core biopsy was carried out and a carcinoma of the breast was recognized. Therefore, the patient was treated with left breast quadrantectomy associated with removal of two sentinel lymph nodes. Pathological examination revealed the presence of intraductal lobular carcinoma; the two lymph nodes were negative. Tumor–node–metastasis stage was pTi.s. pN0 pMx (estrogen and progesterone receptors: negative, Ki67: 30%, p53: 5%, Hercep-test: negative).
The clinical staging for breast cancer was negative. Radiotherapy and hormonotherapy were not prescribed. The patients are actually in follow-up for both melanoma and breast carcinoma.
PET scanning has gained widespread acceptance for the diagnosis, staging, and management of a variety of malignancies, including breast cancer.
Noninvasive breast cancer has been previously shown to be poorly imaged by FDG–PET and the majority of FDG–PET research studies in the literature have been carried out on patients with invasive breast cancer [1]. However, also in patients with invasive breast cancer, sensitivity, specificity, and accuracy of FDG–PET have shown a great variability with different studies [2–4].
The results of FDG–PET for the initial detection and diagnosis of primary invasive breast cancer vary, largely due to heterogeneity of the disease and tumor size.
Moreover, infiltrating ductal carcinoma has a higher level of FDG uptake and therefore is detected at a significantly higher sensitivity than infiltrating lobular breast cancer [5].
No data about the role of FDG–PET in the early detection of noninvasive breast cancer are available in medical literature, but we may expect that sensitivity of FDG–PET should be lower than those for invasive breast cancer. Moreover, this supposition should be true in particular for in situ lobular carcinoma on the basis of what we previously reported.
This report represents the first report of an occasional diagnosis of in situ breast cancer in a patient during the follow-up for a malignant melanoma. In addition, this report is distinctive because also Rx-mammography and ultrasonographic examination of the breast were completely negative. The diagnosis of breast nodule was corroborated only by breast MRI.
Finally, also the histologic type makes this report noteworthy: the ‘in situ lobular carcinoma’ should represent the breast cancer histologic type with the highest false negative on the basis of previously published evidences [6].
In conclusion, in our opinion the role of FDG–PET in the early detection of in situ breast cancer could be put under examination again and this occasional diagnosis during the follow-up for a malignant melanoma could support this idea.
1 Department of Medical Oncology, University Campus Bio-Medico, Rome, Italy
2 Senology Unit, University Campus Bio-Medico, Rome, Ital
* E-mail: b.vincenzi{at}unicampus.it
References
1. Quon A, Gambhir SS. FDG-PET and beyond: molecular breast cancer imaging. J Clin Oncol (2005) 23(8):1664–1673.
2. Avril N, Rose CA, Schelling M, et al. Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol (2000) 18:3495–3502.
3. Wu D, Gambhir SS. Positron emission tomography in diagnosis and management of invasive breast cancer: current status and future perspectives. Clin Breast Cancer (2003) 4:S55–S63.[Medline]
4. Schirrmeister H, Kuhn T, Guhlmann A, et al. Fluorine-18 2-deoxy-2-fluoro-D-glucose PET in the preoperative staging of breast cancer: comparison with the standard staging procedures. Eur J Nucl Med (2001) 28:351–358.[CrossRef][Web of Science][Medline]
5. Crippa F, Agresti R, Seregni E, et al. Prospective evaluation of fluorine-18 FDG PET in presurgical staging of the axilla in breast cancer. J Nucl Med (1998) 39:4–8.
6. Bos R, van Der Hoeven JJ, van Der Wall E, et al. Biologic correlates of [F18]fluorodeoxyglucose uptake in human breast cancer measured by positron emission tomography. J Clin Oncol (2002) 20:379–387.
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