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Impact of FDG PET on Defining the Extent of Disease and on the Treatment of Patients with Recurrent or Metastatic Breast Cancer

William B. Eubank1, David Mankoff2, Mallar Bhattacharya3, Julie Gralow4, Hannah Linden4, Georgiana Ellis4, Skyler Lindsley5, Mary Austin-Seymour5 and Robert Livingston4

1 Department of Radiology, Puget Sound Veterans Affairs Health Care System, 1660 S Columbian Way, S-113-RAD, Seattle, WA 98108.
2 Division of Nuclear Medicine, University of Washington School of Medicine, 1959 NE Pacific St., Seattle, WA 98195-7115.
3 Department of Radiology, University of Washington School of Medicine, Seattle, WA 98195-7115.
4 Division of Medical Oncology, University of Washington School of Medicine, Seattle, WA 98195-7115.
5 Department of Radiation Oncology, University of Washington School of Medicine, Seattle, WA 98195-7115.



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  		Fig. 1. —Bar graph illustrates impact of FDG PET on therapeutic plan by category of referral in 125 patients with advanced breast cancer. Black bars represent patients with locoregional disease, dark gray bars represent patients being evaluated for response to therapy, light gray bars represent patients with equivocal findings on conventional imaging, and white bars represent patients with known metastases being evaluated for extent of disease. Above each category, p values from chi-square analysis of impact of FDG PET on alteration of management plan for each referral category are presented.

 


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  		Fig. 2A. —42-year-old woman who developed recurrence in right mastectomy scar 21 months after surgical resection of infiltrating ductal carcinoma. Results of conventional staging studies (chest CT and bone scan) were negative (not shown). Patient was being considered for aggressive local therapy (surgery and radiation). Coronal image from FDG PET shows uptake in right axilla (arrowhead; maximum standard uptake value [SUV], 6.0).

 


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  		Fig. 2B. —42-year-old woman who developed recurrence in right mastectomy scar 21 months after surgical resection of infiltrating ductal carcinoma. Results of conventional staging studies (chest CT and bone scan) were negative (not shown). Patient was being considered for aggressive local therapy (surgery and radiation). Coronal image from FDG PET shows uptake in mediastinum (arrows; maximum SUV, 2.8). Malignant nodal involvement in mediastinum was confirmed by mediastinoscopy. Because FDG PET indicated more widespread disease than conventional staging examinations, therapeutic plan was altered from primarily local with adjuvant systemic therapy to systemic therapy only.

 


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  		Fig. 3A. —30-year-old woman with axillary node-positive infiltrating ductal carcinoma of left breast and skeletal metastases (midthoracic spine) at initial presentation. Coronal image from baseline FDG PET confirmed disease in thoracic spine (arrow; maximum standard uptake value, 4.5).

 


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  		Fig. 3B. —30-year-old woman with axillary node-positive infiltrating ductal carcinoma of left breast and skeletal metastases (midthoracic spine) at initial presentation. Coronal image from follow-up FDG PET, performed to evaluate response to systemic chemotherapy, shows complete resolution of uptake in spine. FDG PET findings supported decision to pursue consolidation radiation therapy in this patient. She has no evidence of disease 1 year after radiation.

 


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  		Fig. 4A. —54-year-old woman with axillary node-positive infiltrating lobular carcinoma of right breast. Patient had been disease-free on systemic hormonal therapy until 6 years after initial diagnosis when tumor markers became elevated. Posterior projection of restaging bone scan shows multiple foci of radiotracer uptake in spine, pelvis, and right rib, consistent with metastatic disease.

 


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  		Fig. 4B. —54-year-old woman with axillary node-positive infiltrating lobular carcinoma of right breast. Patient had been disease-free on systemic hormonal therapy until 6 years after initial diagnosis when tumor markers became elevated. Posterior coronal image from FDG PET shows no increased uptake at corresponding skeletal sites. Activity in paraspinal regions is due to muscular uptake. Because of newly diagnosed skeletal recurrence, patient was started on systemic chemotherapy.

 

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