To evaluate the role of PET/CT in staging diagnosis in pre-treatment breast cancer patients and finding recurrence lesions, metastases in post-treatment breast cancer patients.
Trang 1THE ROLE OF 18FDG PET/CT IN DIAGNOSIS OF STAGE, RECURRENCE, METASTASES IN BREAST CANCER
PATIENTS PRE- AND POST-TREATMENT
Nguyen Trong Son 1 ; Nguyen Danh Thanh 2
SUMMARY
Objectives: To evaluate the role of PET/CT in staging diagnosis in pre-treatment breast cancer patients and finding recurrence lesions, metastases in post-treatment breast cancer patients Subjects and methods: 55 pre-treatment breast cancer patients were performed
18
FDG PET/CT for initial staging diagnosis and 98 breast cancer patients underwent mastectomy, radiotherapy and/or chemotherapy with clinical symptoms or radiologic findings or rising levels of tumor markers (CA15.3; CEA) had been performed 18 FDG PET/CT to assess the recurrence, metastases Results: 18 FDG PET/CT gave result of increased stage in 21/55 patients (38.2%) included: 15/40 patients (37.5%) in stage II and 6/11 patients (54.5%) in stage III There was no change in patients with stage I These results also changed treatment of choice in 9/55 patients (16.4%) In 98 post-treatment patients, 18 FDG PET/CT detected lymph nodes with increased SUV max in 34/98 patients (34.7%), detected recurrence and distance metastases in 54 patients (55.1%): 12 patients had local recurrence (12.3%), of which 2 patients with local recurrence and distance metastases Bone metastases rate was 22.5%; lung metastases rate was 20.4%; thoracic wall metastases rate was 8.2%; hepatic metastases rate was 8.2% and other metastases rate was 7.1% Conclusion: 18 FDG PET/CT scan effectively detected axillary and extraaxilary nodes, distance metastases, it had great value in stage diagnosis for pre-treatment breast cancer and for following-up, detection of recurrent and metastases in post-treatment breast cancer patients
* Keywords: Metastatic breast cancer; Recurrence; 18 FDG PET/CT
INTRODUCTION
The diagnosis of breast cancer is based
on clinical symptoms, histology and diagnosis
imaging such as mammography, ultrasound,
computed tomography scan (CT-scan)
and magnetic resonance imaging (MRI)
Positron emission tomography/computed
tomography with
fluorine-18-fluoro-deoxyglucose (18FDG PET/CT) can detect
early changes of metabolic shift of disease,
even before physiological and anatomical changes In patients with breast cancer,
18FDG PET/CT had been demonstrated in accurate diagnosis of tumor location, allows to find axillary and extraaxillary lymphatic node (upper and lower clavicular nodes, inner mammary nodes), thoracic and abdominal metastases, bone metastases,
so it can help to evaluate pre-treatment breast cancer stage
1 Viet Duc Hospital
2 103 Military Hospital
Corresponding author: Nguyen Trong Son (ntrongson@yahoo.com)
Date received: 01/10/2019
Trang 218FDG PET/CT also has high accuracy
rate, sensitivity (Se) and specificity (Sp) in
follow up scan to find post-treatment
recurrence and metastases Especially
when patient with clinical symptoms of
recurrence or high serum concentration of
tumor markers but has no abnormal sign
in other conventional imaging method, or
even when patient has no clinical symptoms
In Vietnam, nowadays, it had a few
studies about value of 18FDG PET/CT in
patients with breast cancer However, this
is not yet a systematic, fully documented
about stage diagnosis value of 18FDG
PET/CT
Therefore, this study was carried out
with following objectives: To evaluate the
in pre-treatment breast cancer patients
and for finding recurrence lesions, metastases
in post-treatment breast cancer patients
SUBJECTS AND METHODS
1 Subjects
- Group 1: 55 patients diagnosed with
breast cancer by histopathology were
underwent 18FDG PET/CT scan for
pre-treatment staging diagnosis Patients'
staging according to TNM classification of
American Joint Committee on Cancer (AJCC)
(2017) based on clinical examinations,
CT-scan and MRI
- Group 2: 98 post-treatments (mastectomy
+/- radiotherapy +/- chemotherapy) breast
cancer patients, underwent 18FDG PET/CT
or patients had clinical symptoms, with
recurrence lesions and metastases detected
on other conventional imaging methods or
with high tumor markers concentrations
(CEA, CA15.3) or to post-treatment
follow-up patients
2 Methods
- Study design: Non-control prospective clinical study, cross-sectional description with convenience sampling
- 18FDG PET/CT was processed according
to American College of Radiology (ACR) and European Association of Nuclear Medicine (EANM) guidelines [1, 2]
- 18FDG was produced in Cyclotron Center of 108 Military Central Hospital Used dose: 0.15 mCi/kg (5.55 MBq/kg); injected through venous system 45 minutes before scan process
- PET/CT system: GE PET/CT Discovery ST4 system, Siemens PET/CT Biograph
6 True Point system and GE PET/CT Discovery IQ system
The results were analyzed by both nuclear medicine doctors and radiologists: Identified lesions (tumor, lymph node, distance metastases) with increased
18FDG uptake on PET/CT (SUVmax > 2,5) The staging of patients was compared between pre- and post-FDG PET/CT scan
In post-treatment cancer patient group,
18FDG PET/CT was performed after last treatment at least 3 months to eliminate false positive due to inflammatory after treatments
RESULTS AND DISCUSSION
1 The role of 18 FDG PET/CT in staging breast cancer
Before 18FDG PET/CT scan, the almost
of breast cancer patients were at T1 and T2 stage (85.5%) 14.5% of patients had a large breast tumor with invasion to the skin, chest wall 43.6% of patients
Trang 3detected lymph nodes, of which N1 in
34.5% of patients and N2 - N3 in 9.1% of
patients Stage I was in 7.3% of patients
and stage II accounted for the majority
(72.7%), stages IIIB and IIIC were 20.0%
On 18FDG PET/CT detected primary
tumors in 55/55 patients (100%); tumor
size 0.7 - 7.6 cm; average tumor size was
2.87 ± 1.46 cm
36/55 patients (65.5%) were found
lymph node (axillary lymph nodes, inner
mammary, supraclavicular nodes ) with
the total number of 70 lymph nodes
Distance metastases in the study group were found in 9/55 patients (16.4%), including 2 patients with lung metastases, 2 patients with bone metastases, 2 patients with metastases from contralateral breast, 3 patients with both bone metastases and lung metastases
Of the 9 patients with metastases detected, 4/40 patients (10.0%) were in stage II and 5/11 patients (45.5%) were in stage III before 18FDG PET/CT No patients with stage I before 18FDG PET/CT were detected distance metastases
Before 18 FDG PET/CT After 18 FDG PET/CT
The number of patients with lymph node-negative (N0) decreased, and the number
of patients with lymph node N1 and N3 increased due to the detection of additional lymph nodes in the 18FDG PET/CT image 18FDG PET/CT changed the diagnosis of lymph node stage in 18/55 patients (32.7%), of which 16/55 patients (29.1%) had up-stage and 2/55 patients (3,6%) with reduction up-stage
Before PET/CT Stage TNM after 18 FDG PET/CT
Trang 4- 4 patients with stage I did not change
diagnosis after PET/CT
- 24 patients with stage IIA before
18FDG PET/CT, after 18FDG PET/CT had
stage changes in 11/24 patients (45.8%), of
which 1 patient from T2 to T1 (tumor size
was 1.4 cm) changed from IIA to IA and
10 patients (41.7%) increased the stage,
including:
+ 2 patients changed to stage IV:
1 patient with lung metastases and 1 patient
with contralateral side metastases
+ 6 patients with axillary lymph nodes
changed to stage IIB
+ 1 patient with carina lymph nodes
changed to stage IIIC
+ 1 patient with invasive chest wall
changed to stage IIIB
- 16 patients with stage IIB before 18FDG
PET/CT, after 18FDG PET/CT changed
stage in 6/16 patients (37.5%), including
1 patient from T2 to T1c and so from IIB to
IIA stage, other 5 patients (31.2%) increased
the stage, including:
+ 2 patients changed to stage IV: 1 patient
with opposite side metastases and 1 patient
with multifocal bone metastases
+ 2 patients had invasive skin + chest
wall, from T2 to T4 and so that they changed
to stage IIIB
+ 1 patient found carina lymph node,
changed to stage IIIC
- 8 patients with stage IIIB before
18FDG PET/CT, after 18FDG PET/CT,
there were 4/8 patients (50%) with stage
changes:
+ 3 patients changed to stage IV:
1 patient with lung metastases; 2 patients with lung and bone metastases
+ 1 patient found subclavicular node, changed from N2 to N3 and stage from IIIB
to IIIC
- 2 patients with stage IIIC before 18FDG PET/CT, after 18FDG PET/CT detected
1 patient with lung metastases and bone metastases; 1 patient with multifocal bone metastases Both cases were in stage IV after 18FDG PET/CT
After 18FDG PET/CT, there were 21/55 patients (38.2%) with up-stage, 2/55 patients (3.6%) with reduction stage
The rate of up-stage in patients with stage
II before PET/CT was 37.5% and in stage III before PET/CT was 54.5% 4 patients from stage II and 5 patients from stage III were found metastases and changed to stage IV, so that they had to change the primary treatment method (16.4%)
18FDG PET/CT showed advantages over other imaging methods in detecting lymph nodes like supraclavical nodes, inner mammary nodes, lung and bone metastases 18FDG PET/CT had low sensitivity with brain metastases In patients with high risk such as inflammatory type breast cancer (T4d) or local advanced breast cancer, 18FDG PET/CT had high value
in detecting distance metastases Other study also showed the role of 18FDG PET/CT with breast cancer stage IIB (T2N1/T3N0) [3, 4]
Trang 52 The role of 18 FDG PET/CT in
detecting recurrence and distance
metastases in post-treatment patients
Local recurrence or distance metastases
occur in post-treatment patients Each
year, there are more 2 million new breast
cancer patients and more than 30% of
breast cancer patients have local recurrence
or distance metastases in 15 years after
treatments [5, 6]
In the group of 98 post-treatment
cancer patients, 54.1% of patients had
18FDG PET/CT scan to evaluate and
detect metastatic recurrence The remaining
(45.9%) took 18FDG PET/CT scan because
of signs of relapse, metastasis on conventional
imaging diagnosis (CT, ultrasound, MRI)
and/or CA15.3 marker increased > 25 U/mL
Before 18FDG PET/CT, clinically and/or
by conventional imaging diagnostics (CT,
ultrasound, MRI, radiography ) detected
distance metastases in 17/98 patients
(17.3%) Most common were bone
metastases: 10/98 patients (10.2%) and
lung metastases 4/98 patients (4.1%) On
the ultrasound also detected axillary
nodes in 3 patients and supraclavicular
node in 1 patient; 2 patients had local
recurrence lesions
18FDG PET/CT scan detected lymph
nodes in 34/98 patients (34.7%) The
number of increased uptake 18FDG lymph
node detected in each patient 1 - 6 nodes,
the total number of lymph nodes detected
in 34 patients was 82 The most common
was mediastinal lymph nodes (34/82 patients),
followed by axillary lymph nodes
Table 3: Detected recurrent and
metastases on 18FDG PET/CT in
post-treatment breast cancer patients
Location Number of
patients
Rate (%)
Distance metastases
18FDG PET/CT detected distance metastatic lesions in 17/17 patients (100%), which were detected on conventional imaging and detected further metastatic lesions in 27 other post-treatment breast cancer patients The total number of detected distance metastases was 44/98 patients (44.9%) The most were
bone metastases and lung metastases;
17 patients with metastatic lesions of 2 or more organs 12 patients had a relapse
A total of 78 recurrent lesions and distance metastases were detected in 54 patients
Distance metastases due to breast cancer after treatment were found much
in lungs and bones Brain metastases were detected only when the tumor size was large and the level of 18FDG uptake was high
And besides, recurrence lesions were detected in 12/98 patients (12.3%) In those patients, there were 2 patients had both local recurrence and distance metastases
Trang 6Table 4: The recurrence or metastases detected on 18FDG PET/CT according to the
indicative group
Reason for indicating
post-treatment 18 FDG PET/CT
Number of patients
Patients with recurrent or metastases
Rate (%)
Recurrence, metastases on CT, ultrasound, MRI and
91.7
Patients with suspected recurrence
and distance metastases were detected
on 18FDG PET/CT with recurrent or distance
metastases The rate of recurrence and
distance metastases in the group suspected
of recurrence through conventional imaging
diagnosis and increased serum CA15.3
was 11/12 patients (91.7%) and the group
with high serum CA15.3 was 22/32 (68.7%)
Early and accurate detection of recurrence
and metastases lesions in breast cancer
patients has high value in re-staging and
choosing treatments Local recurrence
can be treated with surgery or radiotherapy;
distance metastases can be treated with
chemotherapy or palliative care PET/CT
is an effective whole body imaging methods
for detecting recurrence, metastases in
cancer in general and breast cancer in
particular with accuracy above 90% [7, 8]
PET/CT has advantages in diagnosis
of recurrence lesions over other imaging
methods with higher sensitivity and specificity,
especially in patients have high concentration
of serum tumor marker In patients without
clinical symptoms but have high biomarker,
18FDG PET/CT can detect metastases
with accuracy up to 87 - 90% while other imaging methods only have accuracy about 50 - 78%
General guidelines recommend post-treatment 18FDG PET/CT scan in patient with pre-treatment stage from II to IIIB, and patient with inflammatory breast cancer
Because in these groups, metastases can
be detected with the highest rate and thought changing the treatment of choice
In our study, 18FDG PET/CT detected all metastases that were already detected
on other methods
CONCLUSIONS
18FDG PET/CT could detect primary tumor in 100% of breast cancer patients, with size 1.1 - 7.6 cm; detected lymph nodes in 36/55 patients (65.5%) with total
of 70 nodes, size from 0.5 - 2.4 cm;
detected distance metastases in 9/55 patients: 2 patients (3.6%) with lung
metastases, 3 patients (5.5%) with lung and bone metastases, 2 patients (3.6%) with bone metastases and 2 patients (3.6%) with contralateral side metastases
Trang 7Compare to clinical based and other
methods based cancer stage, 18FDG PET/CT
gave result of increased stage in
21/55 patients (38.2%) included:
15/40 patients (37.5%) in stage II and
6/11 patients (54.5%) in stage III There
was no change in patients with stage I
These results helped to change treatment
of choice in 9/55 patients (16.4%)
In 98 post-treatment patients, 18FDG
PET/CT detected lymph nodes with increased
SUVmax in 34/98 patients (34.7%) with total
of 82 nodes 18FDG PET/CT also detected
recurrence and distance metastases in 54
patients (55.1%): 12 patients had local
recurrence (12.3%); 2 patients with local
recurrence and distance metastases
Bone metastases rate was 22.5%; lung
metastases rate was 20.4%; thoracic wall
metastases rate was 8.2%; hepatic
metastases rate was 8.2% and other
metastases rate was 7.1% 17 patients
(17.3%) had metastases in at least 2 organs
In post-treatment follow up group,
13/53 patients (24.5%) had metastases
lymph nodes with increased SUVmax and
19/53 patients (35.8%) had recurrence or
distance metastases In patients with
increased CA15.3, 16/32 patients (50%)
had metastases lymph nodes and
22/32 patients (68.7%) had recurrence and
distance metastases
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