Re: Hyland CJ, Varghese F, Yau F, et al. Use of 18F-FDG PET/CT as an initial staging procedure for stage II–III breast cancer: a multicenter value analysis. J Natl Compr Canc Netw 2020;18(11):1510–1517.
We read with interest the article by Hyland et al,1 in which 564 complete records of breast cancer patients with clinical stage II–III disease, who initiated screening for the I-SPY2 trial at 4 institutions, were reviewed to compare staging with FDG-PET/CT versus standard of care (SoC). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Breast Cancer recommend considering CT of the chest, abdomen ± pelvis, and bone scan in appropriate patients.2 At this time, the NCCN Guidelines do not recommend FDG-PET/CT, but state that “FDG-PET/CT may…be helpful in identifying unsuspected regional nodal disease and/or distant metastases when used in addition to standard imaging studies.” In the multicenter study by Hyland et al,1 PET/CT reduced false-positive risk by half and decreased workup for incidental findings, allowing for earlier treatment start. PET/CT was cost-effective, and at one institution was shown to be cost-saving. The de novo metastatic disease rate was 4.6%. However, the authors offer no results by stage or tumor/node combination to help clinical decisions. In another recent study published in JNCCN,3 among 196 patients with breast cancer, the overall upstaging rate to stage IV based on findings of unsuspected distant metastases was 14% (n=27), 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). PET/CT had comparable costs than SoC and had lower radiation dose exposure.3 In another recent retrospective study, PET/CT demonstrated distant disease in 4.9% of 303 patients with stage I or II breast cancer, including 0.8% in stage IIA and 9.8% in stage IIB breast cancer.4 In a prospective study of 254 patients with breast cancer, we detected distant metastases with PET/CT in 2.3% of patients with stage IIA disease, and in 10.7% with clinical stage IIB disease.5 PET/CT had similar performances whatever the breast cancer subtype. Other studies also showed that PET/CT reveals distant metastases in 10% to 15% of patients with stage IIB disease, whatever the breast cancer subtype.5 Nodal metastases outside Berg-I/II levels should also be taken into account, identified with PET/CT, with impact on management.5,6
The 2 recent manuscripts in JNCCN add financial and radiation protection data to support the assertion that FDG-PET/CT should be used in patients with IIB–IIIC breast cancer. We hope this growing evidence will lead consensus guidelines to include FDG-PET/CT for the systemic staging of IIB–IIIC breast cancer at initial diagnosis.
Hyland CJ, Varghese F, Yau C, et al. Use of 18F-FDG PET/CT as an initial staging procedure for stage II-III breast cancer: a multicenter value analysis. J Natl Compr Canc Netw 2020;18:1510–1517.
Gradishar WJ, Moran MS, Abraham J, et al. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer. Version 4.2021. Accessed May 31, 2021. To view the most recent version, visit NCCN.org
Ko H, Baghdadi Y, Love C, et al. Clinical utility of 18F-FDG PET/CT in staging localized breast cancer before initiating preoperative systemic therapy. J Natl Compr Canc Netw 2020;18:1240–1246.
Srour MK, Amersi F. Response to letter to the editor: 18FDG-PET/CT imaging in breast cancer patients with clinical stage IIB or higher. Ann Surg Oncol 2020;27:1710–1711.
Groheux D, Hindié E, Delord M, et al. Prognostic impact of (18)FDG-PET-CT findings in clinical stage III and IIB breast cancer. J Natl Cancer Inst 2012;104:1879–1887.
Ulaner GA. PET/CT for patients with breast cancer: where is the clinical impact? AJR Am J Roentgenol 2019;213:254–265.