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1
Department of Radiology, Memorial Sloan-Kettering Cancer Center, 1275 York
Ave., New York, NY 10021.
2
Weill Medical College of Cornell University, 1300 York Ave., New York, NY
10021.
3
Present address: New York Presbyterian Hospital, 525 E. 68th St., New York, NY
10021.
4
Present address: Lenox Hill Hospital, 100 E. 77th St., New York, NY
10021.
Received September 28, 2000;
accepted after revision November 6, 2000.
Address correspondence to D. M. Panicek.
Abstract
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MATERIALS AND METHODS. The reports of 6628 body CT scans that included images of at least the pelvis in 2426 patients with breast cancer during a 9-year period were reviewed. The presence and sites of reported definite or probable metastases or pelvic tumors were recorded for each scan. Also, the types and results of diagnostic examinations and procedures prompted by equivocal or abnormal findings on pelvic CT were recorded.
RESULTS. Pelvic metastases shown on CT were the only known site of metastasis in 13 (0.5%) of 2426 patients, and four other patients (0.2%) had new or enlarging pelvic metastases despite the presence of stable extrapelvic metastases. The pelvic metastases in these 17 patients were located in bone only in 11 patients, in adnexa only in five patients, and in adnexa, endometrium, and bone in one patient. In addition, pelvic CT led to the performance of 204 additional radiologic examinations, including 186 pelvic sonographic examinations, and 50 surgical procedures; 215 (84.6%) of these 254 additional examinations and procedures yielded normal, benign, or indeterminate results.
CONCLUSION. The routine use of pelvic CT in the evaluation of patients with breast cancer has an extremely low yield and often prompts performance of pelvic sonographic or surgical procedures, the results of which were rarely relevant to cancer therapy.
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Findings on pelvic CT may alter patient treatment if metastatic disease isolated to the pelvis is found or if new or progressive metastases are found only in the pelvis, despite stable or improving metastatic disease elsewhere. However, it has been our anecdotal experience that those specific clinical scenarios rarely occur in our large oncology practice. In fact, we have observed that not only does pelvic CT usually not alter patient treatment substantially but also that findings on pelvic CT often lead to performance of additional examinations and procedures that themselves typically yield normal, benign, or indeterminate results that are not clinically relevant.
Similar to the study of Giess et al. [1] that reported no significant benefit of routine pelvic CT for evaluation of colorectal cancer in 1119 patients, Meyer et al. [2] reported little role for routine pelvic CT in the evaluation of patients with breast cancer; however, their report was based on only 195 CT scans in 139 patients.
We undertook this retrospective review of a large patient population to determine the prevalence of pelvic metastases detected on pelvic CT that would alter oncologic treatment. In addition, we investigated the clinical impact of the additional workup generated by the findings on pelvic CT in these patients.
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We identified 2426 patients who underwent CT of the pelvis (and possibly of other body parts) at least once. The mean age of these women at the time of initial diagnosis of breast cancer was 58.2 years (range, 23-94 years). The pathologic stage of disease at the time of initial diagnosis was known for 1750 (72.1%) of the 2426 patients and was not available in 676 patients. The disease in 48 (2.7%) of these 1750 patients was stage 0; in 366 (20.9%), stage 1; in 1023 (58.5%), stage 2; in 202 (11.5%), stage 3; and in 111 (6.3%), stage 4.
The women underwent a total of 6628 CT examinations (mean, 2.7 scans/patient; range, 1-19 scans). The CT scans included 5888 scans (88.8%) of the chest, abdomen, and pelvis; 645 scans (9.7%) of the abdomen and pelvis; 92 scans (1.4%) of the pelvis alone; and three scans (0.05%) of the chest and pelvis. The specific reason for each CT scan was not examined in this retrospective study, although it was clear from the clinical information on the reports that nearly all scans were performed for initial staging or subsequent restaging of breast cancer. Some of the 92 CT scans of the pelvis alone were obtained, for example, to complete a recent CT scan of the chest and abdomen for treatment protocol purposes; a few scans were obtained to examine known or suspected pelvic disease, although additional reasons may not have been evident from the clinical information listed in the final report. Similarly, in some patients who underwent CT of the abdomen and pelvis (but not of the chest), known specific extrathoracic sites of metastatic disease were being reevaluated, and scanning of the chest was not considered by the referring physician to be essential for patient care. It was not the intent of this study to make value judgments as to whether a particular CT performed in the patient group was clinically appropriate.
Most CT scans were obtained and interpreted at our institution. Several hundred other CT scans were obtained at other facilities but were subsequently officially reinterpreted by radiologists at our institution (at the request of the referring physician). The scans were obtained on a variety of scanners with various protocols; most were performed after administration of IV and oral contrast material.
Data Collection and Analysis
The official report of each CT scan was reviewed by one of five
radiologists. The type and date of each scan and the presence and sites of
definite or probable metastatic disease were recorded. For each scan, note was
made of whether metastases were isolated to the pelvis or whether new or
enlarging metastases were present in the pelvis despite stable or improving
metastases elsewhere. Also, other definite or suspicious pelvic tumors were
noted.
Radiologic examinations and surgical procedures that were performed as a result of equivocal or abnormal findings on pelvic CT were identified, and the results of these were recorded.
To determine whether pelvic metastases were, in fact, isolated to the pelvis and to determine whether lesions actually were metastases, we reviewed other radiology reports and clinical records.
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The breast tumor histology in the 17 patients was infiltrating ductal carcinoma (n = 11), lobular carcinoma (n = 4), and adenocarcinoma not otherwise specified (n = 2). The mean age of these 17 patients at the time of initial diagnosis of breast cancer was 50.1 years (range, 34-67 years). The mean time from initial diagnosis of breast cancer to the detection of the pelvic metastases was 32.5 months (range, 0-110 months).
Among the subgroup of 60 patients who had at least one other known primary neoplasm (in addition to breast cancer), no isolated pelvic metastasis was found.
Additional Examinations and Procedures
The findings on pelvic CT in this patient population prompted the
performance of 254 additional examinations and procedures in 222 patients,
including 204 radiologic examinations and 50 surgical procedures
(Table 1).
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One hundred eighty-six (91.2%) of 204 radiologic examinations were pelvic sonographic examinations, which showed normal, benign, or indeterminate results in 170 examinations (91.4%). Pelvic metastases of breast cancer were confirmed on sonography in five (2.7%) of 186 studies; two of these patients were among the 17 patients with isolated pelvic metastases (n = 1 patient) and new or enlarging pelvic metastases with stable extrapelvic metastases (n = 1 patient). Sonographic findings confirmed unsuspected primary gynecologic tumors in 11 other patients (5.9%), including ovarian carcinoma (n = 3) and endometrial cancer (n = 2).
The most common surgical procedures performed were oophorectomy with or without hysterectomy, endometrial biopsy, and bone biopsy. Breast cancer metastases were found at nine (18%) of 50 surgical procedures; three of these patients were among the 17 patients with isolated pelvic metastases (n = 2 patients) and new pelvic metastases with stable extrapelvic metastases (n = 1 patient). Unsuspected primary pelvic tumors were found at 13 procedures (26%), including ovarian carcinoma (n = 3 patients) and endometrial cancer (n = 2 patients).
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The results of our study show that pelvic CT infrequently yielded information that would alter the treatment of breast cancer in an individual patient. Among the 17 patients in whom isolated pelvic metastases were present or in whom new or enlarging pelvic metastases occurred despite stable extrapelvic metastases, most metastases were in bone—and the presence of the bone metastases was already known from findings of prior bone scans or radiographs. Of course, selective use of pelvic CT in selected patients can be useful, such as for preoperative planning of orthopedic procedures or radiation therapy to palliate bone metastases.
Although pelvic CT can be performed quickly and requires no additional preparation for the patient already undergoing scanning of the abdomen, the cumulative cost and time associated with performing and interpreting this study in large numbers of patients with breast cancer are substantial. Reimbursement for a pelvic CT performed solely for a clinical indication of breast cancer can be difficult to obtain from third-party payers. Moreover, the routine performance of pelvic CT also results in an additional expenditure of medical resources, without substantial benefit to patients, because abnormal or equivocal findings on pelvic CT can lead to the performance of additional examinations and procedures that usually yield normal or clinically insignificant results. In our study, pelvic sonography was the most frequently performed radiologic examination as a result of findings on pelvic CT but rarely contributed to treatment of breast cancer.
Some might argue that pelvic CT is indicated because the incidence of ovarian cancer is elevated in patients with a history of breast cancer. Approximately 3-10% of all women with breast cancer are found to have an inherited mutation in the BRCA1 or BRCA2 genes, which leads to an increased susceptibility to both breast and ovarian cancers [5, 6]. The probability that a patient with breast cancer who has this mutation will develop ovarian cancer may exceed 40%, whereas the probability is only 2% for a patient with breast cancer who lacks this mutation [7]. Because of this high probability, pelvic sonography and measurements of tumor markers such as serum CA 125 are currently being used to screen for ovarian cancer in patients known to have this genetic abnormality. Pelvic CT, however, is not currently recommended as a screening method for detecting ovarian cancer [6].
Adnexal metastases of breast cancer can occur, but adnexa rarely are the only site of metastasis; in the 2426 patients in this study, adnexal metastases were found in 97 patients (4.0%), and only five of these patients (0.2%) had metastases isolated to adnexa.
This study was retrospective, and several factors may have biased our results. For instance, it is difficult to accurately assess retrospectively all the reasons that a particular CT was ordered, and the indications for a given scan were not formally assessed in this study. Yet, it was clear from our review of the clinical statements listed on the CT reports and the frequency with which the scans were obtained in many patients, that most scans were obtained as part of routine patient care, for the purposes of staging and restaging the tumor status and for monitoring the effectiveness of therapy. A small number of CT scans in our study were not obtained solely as part of routine follow-up for breast cancer, but rather for concurrent medical problems such as suspected diverticulitis or new lower back pain or for preoperative planning of orthopedic procedures. As such, those scans are not routine. However, scans are often ordered for several reasons, and more important, the number of isolated metastases shown on pelvic CT was extremely small, even when these few nonroutine CT scans were included.
Not all outside CT studies were submitted to our radiologists for official reinterpretation; the outside reports and the interpretations by referring physicians of many other outside CT studies were used for patient care, without our radiologists' input. Thus, probably a large number of outside CT scans were not included in our study. Some patients were subsequently followed up at other institutions for additional imaging or procedures, so that follow-up was not complete for all patients. Nevertheless, our results were not substantially biased in any systematic way. Our sample was quite large and included patients with all stages of disease. Of note, our results confirm those of the small pilot study reported by Meyer et al. [2]. Sixty patients in this study had more than one known primary neoplasm that potentially could have metastasized to the pelvis; however, no isolated pelvic metastasis, or new or enlarging pelvic metastasis in the presence of stable extrapelvic metastasis, occurred in this small subgroup. We relied on the assessment of disease provided in the final radiology report, similar to what would be done by the referring physician in most cases, without reinterpreting the images. We do not believe this procedure biased our results because this study was not intended to be an assessment of the sensitivity or specificity of CT for pelvic metastases of breast cancer. Also, in a retrospective study, it can be difficult to assess the clinical impact of a test result in some patients. A negative test result certainly can have value, but as shown in this study and in the prior smaller pilot study [2], the percentage of pelvic CT examinations that yielded information that would have caused a change in patient treatment likely was far too low to justify routine use of pelvic CT in this patient population. Finally, no attempt was made to assess the impact of routine pelvic CT on patient survival.
In conclusion, the results of routine pelvic CT rarely provide relevant information that would result in changes in breast cancer therapy. Equally important, abnormal or equivocal findings on pelvic CT can prompt the performance of additional examinations and procedures—most of which yield non-contributory results. Our findings, as well as those of Meyer et al. [2], suggest that pelvic CT has a limited role in a routine follow-up imaging regimen for patients with breast cancer. Pelvic CT can be useful for the evaluation of specific signs or symptoms in patients with breast cancer; of course, its selective role in preoperative planning for certain orthopedic and gynecologic procedures is established.
Although many investigational breast cancer treatment protocols now require that CT of the chest, abdomen, and pelvis be performed at frequent intervals, the requirement for routine pelvic CT should be reconsidered when developing future protocols. Also, additional research (such as a prospective study including a cost-effectiveness analysis) is needed to determine whether any particular subset of patients with breast cancer might benefit from routine pelvic CT.
Acknowledgments
We thank Cathleen A. Cooper for database management.
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