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

European Journal of Nuclear Medicine and Molecular Imaging volume 39, pages 852–863 (2012)Cite this article

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusion

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.

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References

  1. Jemal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ. Cancer statistics, 2009. CA Cancer J Clin. 2009;59:225–49.

    PubMed  Article  Google Scholar 

  2. Kataja V, Castiglione M. Primary breast cancer: ESMO clinical recommendations for diagnosis, treatment and follow-up. Ann Oncol. 2009;20 Suppl 4:10–4.

    PubMed  Google Scholar 

  3. Kreienberg R, Kopp I, Lorenz W, Budach W, Dunst J, Lebeau A, et al. Diagnostik, Therapie und Nachsorge des Mammakarzinoms der Frau. Informationszentrum für Standards in der Onkologie. Berlin: Deutsch Krebsgesellschaft; 2004. p. 2–172.

  4. Kreienberg R, Kopp I, Albert U, Bartsch HH, Beckmann MW, Berg D, et al. Interdisciplinary S3 guidelines for the diagnosis, treatment and follow-up care of breast cancer. 1st updated version. Germering: Zuckschwerdt; 2008. p. 1–308.

  5. Ganz PA. Psychological and social aspects of breast cancer. Oncology (Williston Park). 2008;22:642–6, 650; discussion 650, 653.

    Google Scholar 

  6. Antoch G, Freudenberg LS, Beyer T, Bockisch A, Debatin JF. To enhance or not to enhance? 18F-FDG and CT contrast agents in dual-modality 18F-FDG PET/CT. J Nucl Med. 2004;45 Suppl 1:56S–65S.

    PubMed  CAS  Google Scholar 

  7. Kuehl H, Antoch G. How much CT do we need for PET/CT? A radiologist's perspective. Nuklearmedizin. 2005;44 Suppl 1:S24–31.

    PubMed  Google Scholar 

  8. Poeppel TD, Krause BJ, Heusner TA, Boy C, Bockisch A, Antoch G. PET/CT for the staging and follow-up of patients with malignancies. Eur J Radiol. 2009;70:382–92.

    PubMed  Article  CAS  Google Scholar 

  9. Blodgett TM, Meltzer CC, Townsend DW. PET/CT: form and function. Radiology. 2007;242:360–85.

    PubMed  Article  Google Scholar 

  10. Groheux D, Moretti JL, Giacchetti S, Hindie E, Teyton P, Cuvier C, et al. PET/CT in breast cancer: an update. Bull Cancer. 2009;96:1053–70.

    PubMed  CAS  Google Scholar 

  11. Heusner TA, Kuemmel S, Hahn S, Koeninger A, Otterbach F, Hamami ME, 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. 2009;36:1543–50.

    PubMed  Article  CAS  Google Scholar 

  12. Heusner TA, Kuemmel S, Koeninger A, Hamami ME, Hahn S, Quinsten A, et al. Diagnostic value of diffusion-weighted magnetic resonance imaging (DWI) compared to FDG PET/CT for whole-body breast cancer staging. Eur J Nucl Med Mol Imaging. 37:1077–86.

    Article  Google Scholar 

  13. Dalus K, Rendl G, Rettenbacher L, Pirich C. FDG PET/CT for monitoring response to neoadjuvant chemotherapy in breast cancer patients. Eur J Nucl Med Mol Imaging. 2010;37:1992–3

    PubMed  Article  Google Scholar 

  14. Constantinidou A, Martin A, Sharma B, Johnston SR. Positron emission tomography/computed tomography in the management of recurrent/metastatic breast cancer: a large retrospective study from the Royal Marsden Hospital. Ann Oncol. 2011;22:307–14.

    PubMed  Article  CAS  Google Scholar 

  15. Heusner TA, Freudenberg LS, Kuehl H, Hauth EA, Veit-Haibach P, Forsting M, et al. Whole-body PET/CT-mammography for staging breast cancer: initial results. Br J Radiol. 2008;81:743–8.

    PubMed  Article  Google Scholar 

  16. Heusner TA, Kuemmel S, Umutlu L, Koeninger A, Freudenberg LS, Hauth EA, et al. Breast cancer staging in a single session: whole-body PET/CT mammography. J Nucl Med. 2008;49:1215–22.

    PubMed  Article  Google Scholar 

  17. Groheux D, Hindie E, Rubello D, Espie M, Baillet G, Giacchetti S, et al. Should FDG PET/CT be used for the initial staging of breast cancer? Eur J Nucl Med Mol Imaging. 2009;36:1539–42.

    PubMed  Article  Google Scholar 

  18. Antoch G, Kuehl H, Kanja J, Lauenstein TC, Schneemann H, Hauth E, et al. Dual-modality PET/CT scanning with negative oral contrast agent to avoid artifacts: introduction and evaluation. Radiology. 2004;230:879–85.

    PubMed  Article  Google Scholar 

  19. Edge SB, Compton CC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Ann Surg Oncol. 2010;17:1471–4.

    PubMed  Article  Google Scholar 

  20. Faverly DR, Burgers L, Bult P, Holland R. Three dimensional imaging of mammary ductal carcinoma in situ: clinical implications. Semin Diagn Pathol. 1994;11:193–8.

    PubMed  CAS  Google Scholar 

  21. Groheux D, Moretti JL, Baillet G, Espie M, Giacchetti S, Hindie E, et al. Effect of (18)F-FDG PET/CT imaging in patients with clinical stage II and III breast cancer. Int J Radiat Oncol Biol Phys. 2008;71:695–704.

    PubMed  Article  Google Scholar 

  22. Jacobs MA, Ouwerkerk R, Wolff AC, Gabrielson E, Warzecha H, Jeter S, et al. Monitoring of neoadjuvant chemotherapy using multiparametric, (23)Na sodium MR, and multimodality (PET/CT/MRI) imaging in locally advanced breast cancer. Breast Cancer Res Treat. 2011;128:119–26.

    PubMed  Article  CAS  Google Scholar 

  23. Champion L, Brain E, Giraudet A-L, Le Stanc E, Wartski M, Edeline V, et al. Breast cancer recurrence diagnosis suspected on tumor marker rising: value of whole-body 18FDG-PET/CT imaging and impact on patient management. Cancer. 2011;117:1621–9.

    PubMed  Article  Google Scholar 

  24. Radan L, Ben-Haim S, Bar-Shalom R, Guralnik L, Israel O. The role of FDG-PET/CT in suspected recurrence of breast cancer. Cancer. 2006;107:2545–51.

    PubMed  Article  Google Scholar 

  25. Filippi V, Malamitsi J, Vlachou F, Laspas F, Georgiou E, Prassopoulos V, et al. The impact of FDG-PET/CT on the management of breast cancer patients with elevated tumor markers and negative or equivocal conventional imaging modalities. Nucl Med Commun. 2011;32:85–90.

    PubMed  Article  Google Scholar 

  26. Aukema TS, Rutgers EJ, Vogel WV, Teertstra HJ, Oldenburg HS, Vrancken Peeters MT, et al. The role of FDG PET/CT in patients with locoregional breast cancer recurrence: a comparison to conventional imaging techniques. Eur J Surg Oncol. 2010;36:387–92.

    PubMed  Article  CAS  Google Scholar 

  27. Niikura N, Liu J, Costelloe CM, Palla SL, Madewell JE, Hayashi N, et al. Initial staging impact of fluorodeoxyglucose positron emission tomography/computed tomography in locally advanced breast cancer. Oncologist. 2011;16:772–82.

    PubMed  Article  CAS  Google Scholar 

  28. Alberini JL, Lerebours F, Wartski M, Fourme E, Le Stanc E, Gontier E, et al. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) imaging in the staging and prognosis of inflammatory breast cancer. Cancer. 2009;115:5038–47.

    PubMed  Article  Google Scholar 

  29. Carkaci S, Macapinlac HA, Cristofanilli M, Mawlawi O, Rohren E, Gonzalez Angulo AM, et al. Retrospective study of 18F-FDG PET/CT in the diagnosis of inflammatory breast cancer: preliminary data. J Nucl Med. 2009;50:231–8.

    PubMed  Article  Google Scholar 

  30. Yang WT, Le-Petross HT, Macapinlac H, Carkaci S, Gonzalez-Angulo AM, Dawood S, et al. Inflammatory breast cancer: PET/CT, MRI, mammography, and sonography findings. Breast Cancer Res Treat. 2008;109:417–26.

    PubMed  Article  CAS  Google Scholar 

  31. Rousseau C, Devillers A, Campone M, Campion L, Ferrer L, Sagan C, et al. FDG PET evaluation of early axillary lymph node response to neoadjuvant chemotherapy in stage II and III breast cancer patients. Eur J Nucl Med Mol Imaging. 2011;38:1029–36.

    PubMed  Article  CAS  Google Scholar 

  32. Ueda S, Tsuda H, Saeki T, Osaki A, Shigekawa T, Ishida J, et al. Early reduction in standardized uptake value after one cycle of neoadjuvant chemotherapy measured by sequential FDG PET/CT is an independent predictor of pathological response of primary breast cancer. Breast J. 2010;16:660–2.

    PubMed  Article  Google Scholar 

  33. Groheux D, Giacchetti S, Espie M, Rubello D, Moretti J-L, Hindie E. Early monitoring of response to neoadjuvant chemotherapy in breast cancer with 18F-FDG PET/CT: defining a clinical aim. Eur J Nucl Med Mol Imaging. 2011;38:419–25.

    PubMed  Article  Google Scholar 

  34. Suga K, Kawakami Y, Hiyama A, Matsunaga N. Differentiation of FDG-avid loco-regional recurrent and compromised benign lesions after surgery for breast cancer with dual-time point F-18-fluorodeoxy-glucose PET/CT scan. Ann Nucl Med. 2009;23:399–407.

    PubMed  Article  Google Scholar 

  35. Ueda S, Tsuda H, Asakawa H, Omata J, Fukatsu K, Kondo N, et al. Utility of 18F-fluoro-deoxyglucose emission tomography/computed tomography fusion imaging (18F-FDG PET/CT) in combination with ultrasonography for axillary staging in primary breast cancer. BMC Cancer. 2008;8:165.

    PubMed  Article  Google Scholar 

  36. Gil-Rendo A, Martinez-Regueira F, Zornoza G, Garcia-Velloso MJ, Beorlegui C, Rodriguez-Spiteri N. Association between [18F]fluorodeoxyglucose uptake and prognostic parameters in breast cancer. Br J Surg. 2009;96:166–70.

    PubMed  Article  CAS  Google Scholar 

  37. Kuhl CK. Breast MR imaging at 3T. Magn Reson Imaging Clin N Am. 2007;15:315–20. vi.

    PubMed  Article  Google Scholar 

  38. Heusner TA, Hahn S, Jonkmanns C, Kuemmel S, Otterbach F, Hamami ME, et al. Diagnostic accuracy of fused positron emission tomography/magnetic resonance mammography: initial results. Br J Radiol. 2011;84:126–35.

    PubMed  Article  CAS  Google Scholar 

  39. Veronesi U, Viale G, Paganelli G, Zurrida S, Luini A, Galimberti V, et al. Sentinel lymph node biopsy in breast cancer: ten-year results of a randomized controlled study. Ann Surg. 2010;251:595–600.

    PubMed  Article  Google Scholar 

  40. Brito RA, Valero V, Buzdar AU, Booser DJ, Ames F, Strom E, et al. Long-term results of combined-modality therapy for locally advanced breast cancer with ipsilateral supraclavicular metastases: The University of Texas M.D. Anderson Cancer Center experience. J Clin Oncol. 2001;19:628–33.

    PubMed  CAS  Google Scholar 

  41. Veronesi U, Marubini E, Del Vecchio M, Manzari A, Andreola S, Greco M, et al. Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events. J Natl Cancer Inst. 1995;87:19–27.

    PubMed  Article  CAS  Google Scholar 

  42. Broet P, de la Rochefordiere A, Scholl SM, Fourquet A, De Rycke Y, Pouillart P, et al. Analyzing prognostic factors in breast cancer using a multistate model. Breast Cancer Res Treat. 1999;54:83–9.

    PubMed  Article  CAS  Google Scholar 

  43. Fuster D, Duch J, Paredes P, Velasco M, Munoz M, Santamaria G, et al. Preoperative staging of large primary breast cancer with [18F]fluorodeoxyglucose positron emission tomography/computed tomography compared with conventional imaging procedures. J Clin Oncol. 2008;26:4746–51.

    PubMed  Article  Google Scholar 

  44. Buck AK, Herrmann K, Stargardt T, Dechow T, Krause BJ, Schreyogg J. Economic evaluation of PET and PET/CT in oncology: evidence and methodologic approaches. J Nucl Med. 2010;51:401–12.

    PubMed  Article  Google Scholar 

  45. Yap CS, Seltzer MA, Schiepers C, Gambhir SS, Rao J, Phelps ME, et al. Impact of whole-body 18F-FDG PET on staging and managing patients with breast cancer: the referring physician's perspective. J Nucl Med. 2001;42:1334–7.

    PubMed  CAS  Google Scholar 

  46. Nakai T, Okuyama C, Kubota T, Yamada K, Ushijima Y, Taniike K, et al. Pitfalls of FDG-PET for the diagnosis of osteoblastic bone metastases in patients with breast cancer. Eur J Nucl Med Mol Imaging. 2005;32:1253–8.

    PubMed  Article  Google Scholar 

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Conflicts of interest

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Author information

Affiliations

  1. Medical Faculty, Department of Diagnostic and Interventional Radiology, Univ Dusseldorf, 40225, Dusseldorf, Germany

    C. Riegger, G. Antoch & T. A. Heusner

  2. Medical Faculty, Department of Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, 45147, Essen, Germany

    C. Riegger, J. Herrmann, S. Hahn, T. Lauenstein & T. A. Heusner

  3. Medical Faculty, Department of Nuclear Medicine, University of Duisburg-Essen, 45147, Essen, Germany

    J. Nagarajah & A. Bockisch

  4. Medical Faculty, Department of Gynecology and Obstetrics, University of Duisburg-Essen, 45147, Essen, Germany

    J. Hecktor & S. Kuemmel

  5. Institute of Pathology and Neuropathology, University of Duisburg-Essen, 45147, Essen, Germany

    F. Otterbach

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  1. C. Riegger
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  2. J. Herrmann
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  9. T. Lauenstein
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  10. G. Antoch
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  11. T. A. Heusner
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Correspondence to T. A. Heusner.

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Riegger, C., Herrmann, J., Nagarajah, J. et al. Whole-body FDG PET/CT is more accurate than conventional imaging for staging primary breast cancer patients. Eur J Nucl Med Mol Imaging 39, 852–863 (2012). https://doi.org/10.1007/s00259-012-2077-0

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  • DOI: https://doi.org/10.1007/s00259-012-2077-0

Keywords

  • PET/CT
  • Primary breast cancer
  • Staging
  • Multimodality imaging algorithm