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Diagnostic value of full-dose FDG PET/CT for axillary lymph node staging in breast cancer patients

European Journal of Nuclear Medicine and Molecular Imaging volume 36, pages 1543–1550 (2009)Cite this article

Abstract

Purpose

The aims of this study were (1) to evaluate FDG PET/CT and CT for the detection of axillary lymph node metastases in breast cancer (BC) patients and (2) to evaluate FDG PET/CT as a pre-test for the triage to sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND).

Methods

The sensitivity, specificity, positive and negative predictive value (PPV, NPV), and accuracy of FDG PET/CT and CT for axillary lymph node metastases were determined in 61 patients (gold standard: histopathology). According to the equation “NPV = specificity ∙ (1-prevalence) / [specificity ∙ (1-prevalence) + (1-sensitivity) ∙ prevalence]” FDG PET/CT was evaluated as a triage tool for SLNB versus ALND.

Results

The sensitivity, specificity, PPV, NPV and accuracy of FDG PET/CT was 58, 92, 82, 77 and 79% and of CT 46, 89, 72, 71 and 72%, respectively. Patients with an up to ~60% risk for axillary lymph node metastases appear to be candidates for SLNB provided that the axilla is unremarkable on FDG PET/CT.

Conclusion

FDG PET/CT cannot replace invasive approaches for axillary staging but may extend the indication for SLNB.

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Author information

Affiliations

  1. Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany

    Till A. Heusner, Steffen Hahn, Michael Forsting & Gerald Antoch

  2. Department of Gynecology and Obstetrics, University Hospital Essen, Essen, Germany

    Sherko Kuemmel, Angela Koeninger & Klaus R. Kimmig

  3. Department of Nuclear Medicine, University Hospital Essen, Essen, Germany

    Monia E. Hamami, Andreas Bockisch & Alexander Stahl

  4. Department of Pathology and Neuropathology, University Hospital Essen, Essen, Germany

    Friedrich Otterbach

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  1. Till A. Heusner
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  2. Sherko Kuemmel
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Correspondence to Till A. Heusner.

Additional information

An Editorial Commentary on this paper is available at doi:10.1007/s00259-009-1159-0.

Appendix

Appendix

From a statistical point of view the value of SLNB (as a replacement for ALND) is mainly based on its negative predictive value (NPV) being defined as

$$ NPV = \frac{{specificity \cdot \left( {1 - prevalence} \right)}}{{specificity \cdot \left( {1 - prevalence} \right) + \left( {1 - sensitivity} \right) \cdot prevalence}} $$
(1)

A high NPV obviates the need for ALND in the case of a negative sentinel lymph node (SLN). In institutions where SLNB is applied, an NPV as high as 95% is regularly achieved and considered as sufficiently high [33–36]. Taking into account a virtually 100% specificity of SLNB (in theory there are no false-positive results) and a 91–94% sensitivity [37, 38], the NPV only depends on the prevalence of axillary node disease, according to Eq. 1. Assuming 95% as the lowest value for a tolerable NPV, SLNB should not be applied if the prevalence (= risk) of axillary lymph node metastases exceeds 37% (calculated for a sensitivity of 91%) to 47% (calculated for a sensitivity of 94%, Eq. 1). Otherwise the NPV of SLNB will fall below 95% and may not justify omission of ALND in the case of a negative SLN. The prevalence of axillary lymph node disease in patients with breast cancer shows a strong correlation with tumour size. It is given as ~30% at a size of 1–2 cm, ~45% at 2–3 cm, ~50% at 3–4 cm, ~60% at 4–5 cm and ~70% at > 5 cm. [39–41]. In this manuscript patients with an a priori risk of greater than 40% for axillary lymph node metastases are designated “high-risk” with the remainder being designated “low-risk”.

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Heusner, T.A., Kuemmel, S., Hahn, S. et al. Diagnostic value of full-dose FDG PET/CT for axillary lymph node staging in breast cancer patients. Eur J Nucl Med Mol Imaging 36, 1543–1550 (2009). https://doi.org/10.1007/s00259-009-1145-6

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Keywords

  • FDG
  • PET/CT
  • Breast cancer
  • Sentinel lymph node
  • Axilla