Background:18F-fluorodeoxyglucose PET/CT is recommended as an optional study in the current NCCN Clinical Practice Guidelines in Oncology for Breast Cancer after CT of the chest, abdomen, and pelvis with contrast and bone scan (CTBS) in stage IIA–IIIC breast cancer. We evaluated our experience with the use of PET/CT in this setting before beginning primary systemic therapy (PST) prior to planned surgery. Methods: We performed medical record abstractions of all adult female patients with clinical stage IIA–IIIC breast cancer diagnosed at Montefiore Medical Center from January 1, 2014, through January 1, 2019, who underwent PET/CT before PST. We calculated the proportion of patients upstaged after PET/CT and examined the cost and radiation exposure associated with PET/CT compared with CTBS. Results: A total of 195 patients with 196 breast cancers (bilateral disease in 1 patient) met the study inclusion criteria and had PET/CT as the first imaging study before PST. The overall upstaging rate for regional nodal metastasis and/or distant metastasis was 37% (73/196), including 24% for stage IIA (9/38), 39% for stage IIB (31/79), 54% for stage IIIA (22/41), 27% for stage IIIB (8/30), and 37% for stage IIIC (3/8). The overall upstaging rate for distant metastasis was 14% (27/196), including 0% for stage IIA, 13% for stage IIB (10/79), 22% for stage IIIA (9/41), 17% for stage IIIB (5/30), and 37% for stage IIIC (3/8). Medicare reimbursement rates were $1,604.37 for PET/CT and $1,679.94 for CTBS. The radiation dose for PET/CT was 14 mSv versus 21 mSv for CTBS. Conclusions: Approximately 37% of patients with clinical stage IIA–IIIC breast cancer who underwent PET/CT before PST showed more extensive disease, including 23% with more extensive nodal metastasis and 14% with distant metastasis. Given its high detection rate, comparable cost, lower radiation dose, and greater convenience, PET/CT should be considered as an alternative to CTBS rather than “optional” after CTBS, especially in patients who require an efficient and expeditious workup before initiating PST.
Submitted March 3, 2020; accepted for publication May 13, 2020.
Author contributions:Study design: Ko, Sparano. Patient treatment: Sparano. Data collection and analysis: Ko. Data analysis: Baghdadi. Manuscript writing: All authors. Image interpretations and illustrative images: Baghdadi, Love. Manuscript review and approval: All authors.
Disclosures: The authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.
Correspondence: Heidi Ko, DO, Department of Medical Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, 1695 Eastchester Road, 2nd Floor, Bronx, NY 10461. Email: email@example.com
FisherB, AndersonS, BryantJ, . Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med2002;347:1233–1241.
FisherB, AndersonS, BryantJ, . Twenty-year follow-up of a randomized trial comparing total mastectomy, lumpectomy, and lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347:1233–1241.10.1056/NEJMoa02215212393820)| false
ChampionL, LereboursF, CherelP, . 18F-FDG PET/CT imaging versus dynamic contrast-enhanced CT for staging and prognosis of inflammatory breast cancer. Eur J Nucl Med Mol Imaging 2013;40:1206–1213.2364046710.1007/s00259-013-2405-z)| false
NiikuraN, CostelloeCM, MadewellJE, . FDG-PET/CT compared with conventional imaging in the detection of distant metastases of primary breast cancer. Oncologist 2011;16:1111–1119.2176519310.1634/theoncologist.2011-0089)| false
UlanerGA, CastilloR, WillsJ, . 18F-FDG-PET/CT for systemic staging of patients with newly diagnosed ER-positive and HER2-positive breast cancer. Eur J Nucl Med Mol Imaging 2017;44:1420–1427.2845683710.1007/s00259-017-3709-1)| false
RiedlCC, SlobodE, JochelsonM, . Retrospective analysis of 18F-FDG PET/CT for staging asymptomatic breast cancer patients younger than 40 years. J Nucl Med 2014;55:1578–1583.2521464110.2967/jnumed.114.143297)| false
EdgeSB, ComptonCC. The American Joint Committee on Cancer: the 7th edition of the AJCC cancer Staging Manual and the future of TNM. Ann Surg Oncol 2010;17:1471–1474.10.1245/s10434-010-0985-420180029)| false
CochetA, Dygai-CochetI, RiedingerJM, . 18F-FDG PET/CT provides powerful prognostic stratification in the primary staging of large breast cancer when compared with conventional explorations. Eur J Nucl Med Mol Imaging2014;41:428–437.
CochetA, Dygai-CochetI, RiedingerJM, . 18F-FDG PET/CT provides powerful prognostic stratification in the primary staging of large breast cancer when compared with conventional explorations. Eur J Nucl Med Mol Imaging 2014;41:428–437.2419691610.1007/s00259-013-2595-4)| false
KrammerJ, SchnitzerA, KaiserCG, . 18F-FDG PET/CT for initial staging in breast cancer patients—is there a relevant impact on treatment planning compared to conventional staging modalities?Eur Radiol2015;25:2460–2469.
KrammerJ, SchnitzerA, KaiserCG, . 18F-FDG PET/CT for initial staging in breast cancer patients—is there a relevant impact on treatment planning compared to conventional staging modalities? Eur Radiol 2015;25:2460–2469.10.1007/s00330-015-3630-6)| false