Breast cancer recurrence diagnosis suspected on tumor marker rising

Quarter-Century Transformation of Oncology: Positron Emission Tomography for Patients with Breast Cancer

PET radiotracers have become indispensable in the care of patients with breast cancer. 18F-fluorodeoxyglucose has become the preferred method of many oncologists for systemic staging of breast cancer at initial diagnosis, detecting recurrent disease, and for measuring treatment response after therapy. 18F-Sodium Fluoride is valuable for detection of osseous metastases. 18F-fluoroestradiol is now FDA-approved with multiple appropriate clinical uses. There are multiple PET radiotracers in clinical trials, which may add utility of PET imaging for patients with breast cancer in the future. This article will describe the advances during the last quarter century in PET for patients with breast cancer.

Women's Health Update: Growing Role of PET for Patients with Breast Cancer

Positron Emission Tomography (PET) has been growing in usage for patients with breast cancer, due to an increased number of FDA-approved PET radiotracers pertinent to patients with breast cancer as well as increased prospective evidence for the value of these agents. The leading PET radiotracer for patients with breast cancer is 18F-fluorodeoxyglucose (18F-FDG), which measures glucose metabolism. There is prospective evidence for the use of 18F-FDG PET in systemic staging of newly diagnosed locally advanced breast cancer (stages IIB-IIIC), monitoring breast cancer treatment response, and detecting breast cancer recurrence, particularly in no special type (NST) breast cancer. 16α-18F-fluoro-17β-Fluoroestradiol (18F-FES) is a radiolabeled estrogen which evaluates estrogen receptor (ER) accessible for estrogen binding. There is prospective evidence supporting 18F-FES PET as a predictive biomarker for selecting patients with metastatic breast cancer for endocrine therapies. 18F-FES PET has also been shown to be valuable in the evaluation of ER status of lesions which are difficult to biopsy, for evaluation of ER status in lesions that are equivocal on other imaging modalities, and for selecting optimal dosage of novel ER-targeted systemic therapies in early clinical trials. Multiple investigators have suggested 18F-FES PET will have an increasing role for patients with invasive lobular breast cancer (ILC), which is less optimally evaluated by 18F-FDG PET. Sodium 18F-Fluoride (18F-NaF) evaluates bone turnover and has been effective in evaluation of malignancies which commonly metastasize to bone. In patients with metastatic breast cancer, 18F-NaF PET/CT has demonstrated superior sensitivity for osseous metastases than 99mTc-MDP or CT. In addition to these three FDA-approved PET radiotracers, there are multiple novel radiotracers currently in clinical trials with potential to further increase PET usage for patients with breast cancer.

The current role of nuclear medicine in breast cancer

Breast cancer is the most common cancer in females worldwide. Nuclear medicine plays an important role in patient management, not only in initial staging, but also during follow-up. Radiopharmaceuticals to study breast cancer have been used for over 50 years, and several of these are still used in clinical practice, according to the most recent guideline recommendations.In this critical review, an overview of nuclear medicine procedures used during the last decades is presented. Current clinical indications of each of the conventional nuclear medicine and PET/CT examinations are the focus of this review, and are objectively provided. Radionuclide therapies are also referred, mainly summarising the methods to palliate metastatic bone pain. Finally, recent developments and future perspectives in the field of nuclear medicine are discussed. In this context, the promising potential of new radiopharmaceuticals not only for diagnosis, but also for therapy, and the use of quantitative imaging features as potential biomarkers, are addressed.Despite the long way nuclear medicine has gone through, it looks like it will continue to benefit clinical practice, paving the way to improve healthcare provided to patients with breast cancer.

Influence of [18F]FDG-PET/CT on Clinical Management Decisions in Breast Cancer Patients-A PET/CT Registry Study

There is a lack of evidence regarding the clinical impact of [¹⁸F]fluorodeoxyglucose positron emission tomography/computed tomography ([¹⁸F]FDG-PET/CT, hereinafter referred to as PET/CT), especially regarding management changes and their link to overall survival. We analyzed 52 PET/CTs in 47 stage I-IV breast cancer patients, selected from a prospective oncological PET/CT registry. Indications for PET/CT were primary staging (n = 15), restaging (n = 17), and suspected recurrence (n = 20). PET/CT-induced management changes were categorized as major or minor. PET/CT-induced management changes in 41 of 52 scans (78.8%; 38 of 47 patients (80.9%)), of which major changes were suggested in 18 of 52 scans (34.6%, 17 of 47 patients, 36.2%). PET/CT downstaged 6 of 15 primary staging patients, excluding distant metastases. Major management changes were documented in 3 of 17 restaging exams. PET/CT ruled out clinically suspected recurrence in 6 of 20 cases and confirmed it in 11 of 20. In three cases, locoregional recurrence had already been diagnosed via biopsy. In 30 of 52 exams, additional diagnostic tests were avoided, of which 13 were invasive. PET/CT-based management changes resulted in a 5-year survival rate of 72.3% for the whole study group, 93.3% for the staging group, 53.8% for the restaging group, and 68.4% for the recurrence group. This study shows that PET/CT significantly impacts clinical management decisions in breast cancer patients in different clinical scenarios, potentially determining the patient's tumor stage as the basis for further therapy more reliably and by avoiding unnecessary diagnostic tests.

Performance of [18F]FDG-PET/CT Imaging in First Recurrence of Invasive Lobular Carcinoma

BACKGROUND

Invasive lobular carcinoma accounts for 10 to 15% of all breast cancers. The first objective of this retrospective study was to assess the diagnostic performance of FDG-PET/CT scanning in women previously treated for invasive lobular carcinoma with suspected first recurrence. The secondary objectives were to evaluate the impact of PET/CT in a change in treatment and its prognostic value on specific survival.

METHODS

Patients in whom a PET/CT scan was performed from January 2011 to July 2019 in our Cancer Research Center were enrolled. Recurrence was suspected based on clinical symptoms, abnormal findings on conventional imaging, and/or elevated tumor markers. The diagnosis of recurrence was established by the oncologist after integration of all clinical, biological, histological, imaging, and follow-up data. Prognostic factors of recurrence as predicted by PET were determined using univariate logistic regression. KI67, mitotic index, or grade of mitosis were tested. Survival curves were compared using the log-rank test. Sixty-four patients (mean age: 60.3; SD = 12.4 years) were enrolled. The average time from initial diagnosis of the primary tumor to suspicion of recurrence was 5.2 ± 4.1 years. Forty-eight patients (75%) were judged to have recurrence by the oncologist: 7 local and 41 metastatic, with mainly bone (n = 24), lymph node (n = 14) and liver (n = 10) metastases.

RESULTS

Sensitivity, specificity, and positive and negative predictive values of PET/CT to predict recurrence were, respectively: 87%, 87%, 95%, and 70%. SUVmax at recurrence sites was generally high (mean: 6.4; SD = 2.9). False negative PET/CT results occurred with local (n = 2), peritoneal (n = 2), meningeal (n = 1), or bladder (n = 1) recurrences. In 40 patients with available histopathological data from suspected sites of recurrence, 30 PET/CT were true positive. In four patients, primary lung (n = 1) or gastric (n = 1) tumors or lymphomas (n = 2) were found. The detection of a recurrence resulted in a change in treatment in 44/48 patients (92%). No association between recurrence predicted by PET and biological biomarkers was found. Median specific survival appears shorter in patients with metastatic recurrence versus patients with local or no recurrence on PET/CT (p = 0.067).

CONCLUSIONS

FDG-PET/CT is an effective and reliable tool for the detection of invasive lobular carcinoma recurrence, although certain recurrence sites specific to this histological type can impair its diagnostic performance.

FDG-PET/CT for Primary Staging and Detection of Recurrence of Breast Cancer

Breast cancer is the most frequent cancer diagnosed in women worldwide. Accurate baseline staging is necessary to plan optimal breast cancer management. Early detection and staging of recurrence are also essential for optimal therapeutic management. Hybrid FDG-PET/CT imaging offers high sensitivity in detecting extra axillary lymph nodes and distant metastases. Although FDG-PET/CT has some limitations for low proliferative tumors, low-grade tumors and for well-differentiated luminal breast cancer, PET/CT is useful for the initial staging of breast cancer, regardless of tumor phenotype (luminal, triple negative, or HER2+) and of tumor grade. Although FDG-PET/CT performs better for invasive ductal carcinoma (invasive carcinoma of no specific subtype), it is also helpful for staging invasive lobular carcinomas. At initial staging, FDG-PET/CT becomes very useful for staging from clinical stage IIB (T2N1 or T3N0). FDG-PET/CT could be useful in patients with clinical stage IIA (T1N1 or T2N0), but there is not enough strong evidence to recommend routine use in this subgroup. For clinical stage I (T1N0) patients, FDG-PET/CT offers no added value. In patients with recurrent breast cancer, FDG-PET/CT is more effective than conventional imaging in detecting locoregional or distant recurrence, whether suspected by clinical examination, conventional imaging, or elevation of a tumor marker (CA 15.3 or CEA). PET/CT is effective even in the presence of normal tumor markers. PET/CT is also a powerful imaging modality for performing a whole-body workup of a known recurrence and for determining whether or not the recurrence is isolated.

Head-to-Head Comparison between 18F-FES PET/CT and 18F-FDG PET/CT in Oestrogen Receptor-Positive Breast Cancer: A Systematic Review and Meta-Analysis

¹⁸F-FDG PET/CT is a powerful diagnostic tool in breast cancer (BC). However, it might have a reduced sensitivity in differentiated, oestrogen receptor-positive (ER+) BC. In this setting, specific molecular imaging with fluorine-oestradiol (¹⁸F-FES) PET/CT could help in overcoming these limitations; however, the literature on the diagnostic accuracy of this method is limited. We therefore planned this systematic review and meta-analysis to compare ¹⁸F-FDG and ¹⁸F-FES PET/CT in ER+ BC patients. We performed a literature search to identify all studies performing a head-to-head comparison between the two methods; we excluded review articles, preclinical studies, case reports and small case series. Finally, seven studies were identified (overall: 171 patients; range: 7–49 patients). A patients-based analysis (PBA) showed that ¹⁸F-FDG and ¹⁸F-FES PET/CT had a similar high pooled sensitivity (97% and 94%, respectively) at the lesion-based analysis (LBA), ¹⁸F-FES performed slightly better than ¹⁸F-FDG (pooled sensitivity: 95% vs. 85%, respectively). Moreover, when we considered only the studies dealing with the restaging setting (n = 3), this difference in sensitivity was even more marked (98% vs. 81%, respectively). In conclusion, both tracers feature an excellent sensitivity in ER+ BC; however, ¹⁸F-FES PET/CT could be preferred in the restaging setting.

PET/CT Variants and Pitfalls in Breast Cancers

There are a number of normal variants and pitfalls which are important to consider when evaluating F-18 Fluorodeoxyglucose (FDG) with Positron Emission Tomography (PET) in breast cancer patients. Although FDG-PET is not indicated for the initial diagnosis of breast cancer, focally increased glucose metabolism within breast tissue represents a high likelihood for a neoplastic process and requires further evaluation. Focally increased glucose metabolism is not unique to breast cancer. Other malignancies such as lymphoma, metastases from solid tumors as well as inflammatory changes also may demonstrate increased glucose metabolism either within the breast or at other sites throughout the body. Importantly, benign breast disease may also exhibit increased glucose metabolism, limiting the specificity of FDG-PET. Breast cancer has a wide range of metabolic activity attributed to tumor heterogeneity and breast cancer subtype. Intracellular signaling pathways regulating tumor glucose utilization contribute to these pitfalls of PET/CT in breast cancer. The evaluation of axillary lymph nodes by FDG-PET is less accurate than sentinel lymph node procedure, however is very accurate in identifying level II and III axillary lymph node metastases or retropectoral metastases. It is important to note that non-malignant inflammation in lymph nodes are often detected by modern PET/CT technology. Therefore, particular consideration should be given to recent vaccinations, particularly to COVID-19, which can commonly result in increased metabolic activity of axillary nodes. Whole body FDG-PET for staging of breast cancer requires specific attention to physiologic variants of FDG distribution and a careful comparison with co-registered anatomical imaging. The most important pitfalls are related to inflammatory changes including sarcoidosis, sarcoid like reactions, and other granulomatous diseases as well as secondary neoplastic processes.

Higher Interrater Agreement of FDG-PET/CT than Bone Scintigraphy in Diagnosing Bone Recurrent Breast Cancer

The purpose was to investigate the interrater agreement of FDG-PET/CT and bone scintigraphy for diagnosing bone recurrence in breast cancer patients. A total of 100 women with suspected recurrence of breast cancer underwent planar whole-body bone scintigraphy with [99mTc]DPD and FDG-PET/CT. Scans were evaluated independently by experienced nuclear medicine physicians and the results for one modality were blinded to the other. Images were visually interpreted using a 4-point assessment scale (0 = no metastases, 1 = probably no metastases, 2 = probably metastases, 3 = definite metastases). Out of 100 women, 22 (22%) were verified with distant recurrence, 18 of these had bone involvement. The proportions of agreement between readers were 93% (86.3-96.6) for bone recurrence with FDG-PET/CT and 47% (37.5-56.7) for bone recurrence with planar bone scintigraphy. The strengths of agreement between readers for diagnosing bone recurrence was 'almost perfect' with FDG-PET/CT and was 'fair' with planar bone scintigraphy according to Cohen's kappa value of 0.82 (0.70-0.95) and 0.28 (0.18-0.39), respectively. Interrater agreement yielded improved reproducibility with FDG-PET/CT versus with bone scintigraphy when diagnosing recurrence with bone metastasis in this patient cohort.

Fluorodeoxyglucose positron emission tomography/computed tomography findings after percutaneous cryoablation of early breast cancer

BACKGROUND

To document ¹⁸F-Fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings after percutaneous cryoablation for early breast cancer.

METHODS

Data of 193 consecutive patients who had undergone cryoablation for invasive ductal carcinoma or ductal carcinoma in situ ≤ 15 mm without a history of ipsilateral breast cancer, synchronous ipsilateral lesion, and with estrogen receptor positive/human epidermal growth factor 2 negative were enrolled. The imaging characteristics of the treated areas were evaluated and classified on CT images as one of two types: fatty mass or non-fatty mass type. The maximum standardized uptake value (SUVmax) of the initial post-cryoablation PET/CT, the CT type of the treated area and selected clinical factors (age, menopausal status, lesion area, breast density, timing of PET/CT) were retrospectively evaluated.

RESULTS

The median interval between cryoablation and the initial post-cryoablation PET/CT was 12 months. The median SUVmax of the treated area was 1.36. The CT findings of the treated area were classified as fatty mass type (n = 137, 71.0%) or non-fatty mass type (n = 56, 29.0%). The treated areas of patients with lower breast density, of older age, post-menopausal status, and lower radiation dose were significantly more likely to be of fatty mass type (P < 0.001). Non-fatty mass type averaged a significantly higher SUVmax than did fatty mass type.

CONCLUSIONS

Post-cryoablation PET/CT findings are of fatty or non-fatty mass type. A non-fatty appearance, which can show higher SUVmax, does not necessarily denote recurrence.

How Useful Are Tumor Markers in Detecting Metastases with FDG-PET/CT during Breast Cancer Surveillance?

BACKGROUND

To assess the clinical usefulness of serum tumor markers for early detection of distant breast cancer recurrence using FDG-PET/CT.

METHODS

We retrospectively analyzed 561 consecutive patients who underwent surgery for invasive primary breast cancer and had increased tumor markers (CA 15-3 and CEA) after completion of locoregional therapy. FDG-PET/CT data were reviewed for all cases. CA 15-3 and CEA were evaluated both in a continuous and in a quartile (Q) distribution. The Wilcoxon rank-sum test and logistic regression models were used to evaluate the association between increased tumor marker values and the presence (and type) of distant metastases.

RESULTS

The median value of CA 15-3 was 35.0 U/mL (IQR, 29.5-43.0) in cases where no distant metastases were detected, and it was 58.9 U/mL (IQR, 40.0-108.0) in cases where metastases were detected (p < 0.001). The median value of CEA was 6.6 U/mL (IQR, 4.4-10.0) in cases of no metastases and 12.4 U/mL (IQR, 6.9-30.0) in cases of metastases (p < 0.001). Increased levels of both tumor markers (Q3 and Q4) were strongly associated with the presence of distant metastases. The association between CA 15-3 and bone/liver metastases was stronger compared with other types of metastases (p heterogeneity between odds ratios [ORs] = 0.03 for Q3 and <0.001 for Q4), while no relevant heterogeneity between ORs emerged for CEA.

CONCLUSION

Increased tumor marker levels detected in asymptomatic breast cancer patients during adjuvant therapies and follow-up are significantly predictive of distant metastases identified on FDG-PET/CT.

Comparison of diagnostic sensitivity of [18F]fluoroestradiol and [18F]fluorodeoxyglucose positron emission tomography/computed tomography for breast cancer recurrence in patients with a history of estrogen receptor-positive primary breast cancer

BACKGROUND

To compare the diagnostic sensitivity of [¹⁸F]fluoroestradiol ([¹⁸F]FES) and [¹⁸F]fluorodeoxyglucose ([¹⁸F]FDG) positron emission tomography/computed tomography (PET/CT) for breast cancer recurrence in patients with estrogen receptor (ER)-positive primary breast cancer.

METHODS

Our database of consecutive patients enrolled in a previous prospective cohort study to assess [¹⁸F]FES PET/CT was reviewed to identify eligible patients who had ER-positive primary breast cancer with suspected first recurrence at presentation and who underwent [¹⁸F]FDG PET/CT. The sensitivity of qualitative [¹⁸F]FES and [¹⁸F]FDG PET/CT interpretations was assessed, comparing them with histological diagnoses.

RESULTS

Of the 46 enrolled patients, 45 were confirmed as having recurrent breast cancer, while one was diagnosed with chronic granulomatous inflammation. Forty (89%) patients were ER-positive, four (9%) were ER-negative, and one (2%) patient did not undergo an ER assay. The sensitivity of [¹⁸F]FES PET/CT was 71.1% (32/45, 95% CI, 55.7-83.6), while that of [¹⁸F]FDG PET/CT was 80.0% (36/45, 95% CI, 65.4-90.4) with a threshold of positive interpretation, and 93.3% (42/45, 95% CI, 81.7-98.6) when a threshold of equivocal was used. There was no significant difference in sensitivity between [¹⁸F]FES and [¹⁸F]FDG PET/CT (P = 0.48) with a threshold of positive [¹⁸F]FDG uptake, but the sensitivity of [¹⁸F]FDG was significantly higher than [¹⁸F]FES (P = 0.013) with a threshold of equivocal [¹⁸F]FDG uptake. One patient with a benign lesion showed negative [¹⁸F]FES but positive [¹⁸F]FDG uptake.

CONCLUSIONS

The restaging of patients who had ER-positive primary breast cancer and present with recurrent disease may include [¹⁸F]FES PET/CT as an initial test when standard imaging studies are equivocal or suspicious.

Early metabolic response of breast cancer to neoadjuvant endocrine therapy: comparison to morphological and pathological response

Background

Neoadjuvant endocrine therapy (NET) has shown efficacy in terms of clinical response and surgical outcome in postmenopausal patients with estrogen receptor-positive / HER2-negative breast cancer (ER+/HER2- BC) but monitoring of tumor response is challenging. The aim of the present study was to investigate the value of an early metabolic response compared to morphological and pathological responses in this population.

Methods

This was an ancillary study of CARMINA 02, a phase II clinical trial evaluating side-by-side the efficacy of 4 to 6 months of anastrozole or fulvestrant. Positron Emission Tomography/Computed Tomography using 2-deoxy-2-[¹⁸F]fluoro-D-glucose (FDG-PET/CT) scans were performed at baseline (M0), early after 1 month of treatment (M1) and pre-operatively in 11 patients (74.2 yo ± 3.6). Patients were classified as early “metabolic responders” (mR) when the decrease of SUVmax was higher than 40%, and “metabolic non-responders” (mNR) otherwise. Early metabolic response was compared to morphological response (palpation, US and MRI), variation of Ki-67 index, pathological response according to the Sataloff classification and also to Preoperative Endocrine Prognostic Index (PEPI) score. It was also correlated with overall survival (OS) and recurrence-free survival (RFS).

Results

Tumor size measured on US and on MRI was smaller in mR than mNR, with the highest statistically significant difference at M1 (p = 0.01 and 7.1 × 10^− 5, respectively). No statistically significant difference in the variation of tumor size between M0 and M1 assessed on US or MRI was observed between mR and mNR. mR had a better clinical response: no progressive disease in mR vs 2 in mNR and 2 partial response in mR vs 1 partial response in mNR. One patient with a pre-operative complete metabolic response had the best pathological response. Pathological response did not show any statistically significant difference between mR and mNR. mR had better OS and RFS (Kaplan-Meier p = 0.08 and 0.06, respectively). All cancer-related events occurred in mNR: 3 patients died, 2 of them from progressive disease.

Conclusions

FDG-PET/CT imaging could become a “surrogate marker” to monitor tumor response, especially as NET is a valuable treatment option in postmenopausal women with ER+/HER2- BC.

The Evolving Role of FDG-PET/CT in the Diagnosis, Staging, and Treatment of Breast Cancer

The applications of 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/X-ray computed tomography (PET/CT) in the management of patients with breast cancer have been extensively studied. According to these studies, PET/CT is not routinely performed for the diagnosis of primary breast cancer, although PET/CT in specific subtypes of breast cancer correlates with histopathologic features of the primary tumor. PET/CT can detect metastases to mediastinal, axial, and internal mammary nodes, but it cannot replace the sentinel node biopsy. In detection of distant metastases, this imaging tool may have a better accuracy in detecting lytic bone metastases compared to bone scintigraphy. Thus, PET/CT is recommended when advanced-stage disease is suspected, and conventional modalities are inconclusive. Also, PET/CT has a high sensitivity and specificity to detect loco-regional recurrence and is recommended in asymptomatic patients with rising tumor markers. Numerous studies support the future role of PET/CT in prediction of response to neoadjuvant chemotherapy (NAC). PET/CT has a higher diagnostic value for prognostic risk stratification in comparison with conventional modalities. With the continuing research on the treatment planning and evaluation of patients with breast cancer, the role of PET/CT can be further extended.

Diagnostic and prognostic value of 18F-FDG PET/CT imaging in suspected recurrence of male breast cancer

Purpose

Male breast cancer (MBC) is a rare malignancy, with recurrence being one of the main adverse predictors for prognosis. The aim of the study was to evaluate the diagnostic and predictive value of fluorine-18-fluorodeoxyglucose (¹⁸F-FDG) PET/CT in the setting of suspected recurrence of MBC.

Patients and methods

Retrospective analysis of PET/CT findings was performed in 23 previously treated, histologically proven patients with MBC (mean age: 59.3±10.9 years; range: 36–79 years) with suspected recurrence. Kaplan–Meier disease-specific survival analysis was made with respect to histological, hormonal profile as well as PET/CT findings.

Results

Of the 23 patients, 19 (82.6%) showed recurrence. Recurrence at primary site with/without regional/distant site recurrence was seen in 12 (52.2%) patients. Only metastatic recurrence without primary site was seen in seven (30.4%) patients. Bone was the most common site of distant metastasis (14/23) followed by lungs (9/23), liver (4/23), brain (2/23), and adrenal (1/23). No recurrence (regional/distant) was noted in 4/23 (17.3%) patients; however, three of them had ¹⁸F-FDG-avid soft tissue lesions in esophagus, rectum and tongue, correspondingly, confirmed as second primaries with histopathology. Disease-specific survival analysis yielded nodal (P=0.01) as well as distant metastases (P=0.02) as the main survival predictors on PET/CT. Lung (P=0.001), followed by liver (P=0.009), and skeletal (P=0.01) metastases were the most adverse survival predictive factors.

Conclusion

¹⁸F-FDG PET/CT showed good diagnostic and prognostic utility in recurrent MBC. It was better than bone scan in evaluation of skeletal metastases. Most importantly, ¹⁸F-FDG PET/CT helped in early detection of second malignancy and their clinical management in studied patients.

Influence of age on radiomic features in 18F-FDG PET in normal breast tissue and in breast cancer tumors

Background

To help interpret measurements in breast tissue and breast tumors from ¹⁸F-FDG PET scans, we studied the influence of age in measurements of PET parameters in normal breast tissue and in a breast cancer (BC) population.

Results

522 women were included: 331 pts without history of BC (B-VOI) and 191 patients with BC (T-VOI). In B-VOI, there were significant differences between all age groups for Standardized Uptake Values (SUVs) and for 12 textural indices (TI) whereas histogram-based indices (HBI) did not vary between age groups. SUV values decreased over time whereas Homogeneity increased. We had a total of 210 T-VOI and no significant differences were found according to the histological type between 190 ductal carcinoma and 18 lobular carcinoma. Conversely, according to BC subtype most differences in PET parameters between age groups were found in Triple-Negative tumors (52) for 9 TI. On post-hoc Hochberg, most differences were found between the <45 year old (PRE) group and POST groups in NBT and in Triple-Negative tumors.

Conclusion

We found significant SUVs and TI differences as a function of age in normal breast tissue and in BC radiomic phenotype with Triple-Negative tumors being the most affected. Our findings suggest that age should be taken into account as a co-covariable in radiomic models.

Methods

Patients were classified in 3 age groups: <45 yo (PRE), ≥45 and <55 yo (PERI) and ≥55 and <85 yo (POST) and we compared PET parameters using Anova test with post-hoc Bonferroni/Hochberg analyses: SUV (max, mean and peak), HBI and TI in both breasts and in breast tumor regions.

Early re-staging and molecular subtype shift surveillance of locally recurrent or metastatic breast cancer: A new PET/CT integrated precise algorithm

Recurrent breast cancer poses considerable diagnostic and therapeutic challenges for clinic. Clinical suspicion of recurrence must be first confirmed by imaging studies. Then re-biopsy of suspected recurrence and metastasis in patients with breast cancer is recommended in the practice guidelines of the National Comprehensive Cancer Network (NCCN) and European Society for Medical Oncology (ESMO) to confirm whether the molecular subtype changes. It may change the individual treatment plan directly. Our research provided an integrated algorithm for locally recurrent or distant metastatic breast cancer, including early relapse detection and subsequently a new practical PET/CT imaging guide biopsy approach for surveilling molecular subtype shifts of the recurrent breast cancer. In our results, ¹⁸F-FDG PET/CT appears to be more sensitive and accurate than conventional imaging technologies in early detecting locally recurrent or metastatic breast cancer. PET/CT-guided percutaneous FDG-avid target biopsies offers a new integrated precise re-biopsy algorithm for pathologic confirm and surveillance of molecular subtype shifts of the recurrent breast cancer. The precise algorithm for breast cancer recurrence and metastasis can be established in one stop, opening a window of opportunity for breast cancer patients to improve precise individual therapy and prolong survival.

CA 15.3 measurements for separating FDG PET/CT positive from negative findings in breast carcinoma recurrence

In breast cancer CA 15.3 is considered the tumour marker of choice. CA 15.3 is directly related to the disease extent and to hormone status (estrogen receptor ER+/ ER-, progesterone receptor PR+/PR-). This study was designed to assess the impact of disease extent, hormone receptor and HER2-status, and circulating blood volume on the area-under the ROC-curve of CA 15.3 to separate FDG PET positive from negative findings. Patients, methods: We retrospectively evaluated 379 FDG PET/CT examinations performed in 80 patients with breast cancer. Blood volumes were derived using the formulas by Nadler and multiplied by their corresponding CA 15.3 measurement. Results: ROC-curve analysis revealed an AUC of 0.695 (p = 0.0001) for CA 15.3 to separate FDG PET positive from negative findings. AUC measurements to separate normal scan find-ings from loco-regional disease and meta- static disease were 0.527 (p = 0.587) and 0.732 (p = 0.0001), respectively. AUC measurements for CA 15.3 to separate positive from negative FDG PET findings, in ER+ and ER- patients, were respectively 0.772 (p = 0.0001) and 0.596 (p = 0.143). AUC measurements for CA 15.3 to separate positive from negative FDG PET findings, in PR+ and PR- patients, were respectively 0.675 (p = 0.0001) and 0.694 (p = 0.0001). In HER2-positive and -negative patients, the AUC measurements were respectively 0.594 (p = 0.178) and 0.701 (p = 0.0001) to separate positive from negative FDG PET findings. Conclusion: The AUC for CA 15.3 measurements to separate FDG PET positive from negative findings in breast cancer patients with suspected recurrence proved to be directly related to the extent of the recurrent disease and hormone receptor status and inversely related to HER2-status. Correcting CA 15.3 measurements for blood volumes did not impact the AUC.

FDG-PET/CT in the Postoperative Period: Utility, Expected Findings, Complications, and Pitfalls

FDG-PET/CT as a modality is increasingly used for detection of recurrence and for restaging in patients with clinical suspicion of malignancy, as well as in patients with elevated tumor markers. However, there are many pitfalls in the interpretation of these scans when the studies are performed after some treatment. Some of these are attributed to normal physiological distribution and are compounded when there are inflammatory changes occurring after surgery. The body's inherent response to the surgical insult results in this inflammation. In addition, there are also complications that can happen following surgery, causing increased FDG uptake. Despite various fallacies, FDG-PET/CT provides valuable information in evaluation of residual and recurrent malignant disease. In this article, we aim to describe some of these postsurgical changes secondary to inflammation, common surgical complications, and finally, the utility of FDG-PET/CT in these patients to detect recurrent disease, even in the background of postsurgical changes.

Relationship between computed tomography morphology and prognosis of patients with stage I non-small cell lung cancer

This study aimed to explore the relationship between computed tomography morphology and prognosis of patients with stage I non-small cell lung cancer (NSCLC). From May 2009 to May 2011, a total of 124 patients diagnosed with stage I NSCLC were included. All patients had complete chest computed tomography scans. Five-year follow-up was conducted. Univariate and multivariate Cox regression analyses were performed to estimate the prognostic factors for patients with stage I NSCLC. The 5-year survival rate was 67.74% (84/124). The 5-year survival rates of patients with stage T1a, T1b, and T2a were 89.19%, 75.00%, and 41.86%, respectively. The 5-year survival rates of patients with homogeneity, inhomogeneity, vacuole, and cavity were 68.42%, 72.09%, 59.46%, and 83.33%, respectively. The 5-year survival rates of patients with different margin features were 83.33% (slick margin), 79.73% (lobulation sign), and 39.47% (short burr). The 5-year survival rates of patients with normal, halo, vessel convergence, bronchial transection, and vascular bundle thickening were 84.38%, 72.73%, 71.79%, 52.00%, and 47.06%, respectively. The 5-year survival rates of patients with normal and pleura thickening/indentation were 81.93% and 39.02%. Univariate analysis demonstrated that tumor node metastasis staging, tumor margin, tumor periphery, and pleural invasion were related to the prognosis of stage I NSCLC patients. Cox regression analysis confirmed that T2a stage, pleura thickening/indentation were independent risk factors for poor prognosis of stage I NSCLC. In conclusion, our findings indicate that T2a stage, pleura thickening/indentation might be prognostic factors in stage I NSCLC.

The application of positron emission tomography (PET/CT) in diagnosis of breast cancer. Part II. Diagnosis after treatment initiation, future perspectives

Similarly to the applications described in the first part of this publication, positron emission tomography with computed tomography (PET/CT) is also gaining importance in monitoring a tumour's response to therapy and diagnosing breast cancer recurrences. This is additionally caused by the fact that many new techniques (dual-time point imaging, positron emission tomography with magnetic resonance PET/MR, PET/CT mammography) and radiotracers (16α-18F-fluoro-17β-estradiol, 18F-fluorothymidine) are under investigation. The highest sensitivity and specificity when monitoring response to treatment is achieved when the PET/CT scan is made after one or two chemotherapy courses. Response to anti-hormonal treatment can also be monitored, also when new radiotracers, such as FES, are used. When monitoring breast cancer recurrences during follow-up, PET/CT has higher sensitivity than conventional imaging modalities, making it possible to monitor the whole body simultaneously. New techniques and radiotracers enhance the sensitivity and specificity of PET and this is why, despite relatively high costs, it might become more widespread in monitoring response to treatment and breast cancer recurrences.

¹⁸F-FDG PET/CT for Staging and Restaging of Breast Cancer

Many studies have pointed out the role of (18)F-FDG PET/CT (or (18)F-FDG PET) in patients with clinical stage III or II breast cancer. (18)F-FDG PET/CT might advantageously replace other staging procedures, such as bone scanning and possibly contrast-enhanced CT of the thorax or abdomen-pelvis. We discuss the findings, locoregional or distant, that can be expected in different categories of breast cancer and their impact on prognosis and management. We also discuss the role of (18)F-FDG PET/CT in restaging and how (18)F-FDG PET/CT compares with conventional techniques in restaging for patients with suspected disease recurrence. We conclude with some recommendations for clinical practice and future research.

Cadherin-5: a biomarker for metastatic breast cancer with optimum efficacy in oestrogen receptor-positive breast cancers with vascular invasion

BACKGROUND

A glycoproteomic study has previously shown cadherin-5 (CDH5) to be a serological marker of metastatic breast cancer when both protein levels and glycosylation status were assessed. In this study we aimed to further validate the utility of CDH5 as a biomarker for breast cancer progression.

METHODS

A nested case-control study of serum samples from breast cancer patients, of which n=52 had developed a distant metastatic recurrence within 5 years post-diagnosis and n=60 had remained recurrence-free. ELISAs were used to quantify patient serum CDH5 levels and assess glycosylation by Helix pomatia agglutinin (HPA) binding. Clinicopathological, treatment and lifestyle factors associated with metastasis and elevated biomarker levels were identified.

RESULTS

Elevated CDH5 levels (P=0.028) and ratios of CDH5:HPA binding (P=0.007) distinguished patients with metastatic disease from those that remained metastasis-free. Multivariate analysis showed that the association between CDH5:HPA ratio and the formation of distant metastases was driven by patients with oestrogen receptor (ER+) positive cancer with vascular invasion (VI+).

CONCLUSIONS

CDH5 levels and the CDH5 glycosylation represent biomarker tests that distinguish patients with metastatic breast cancer from those that remain metastasis-free. The test reached optimal sensitivity and specificity in ER-positive cancers with vascular invasion.

[18F]Fluorodeoxyglucose (FDG)-Positron Emission Tomography (PET)/Computed Tomography (CT) in Suspected Recurrent Breast Cancer: A Prospective Comparative Study of Dual-Time-Point FDG-PET/CT, Contrast-Enhanced CT, and Bone Scintigraphy

PURPOSE

To prospectively investigate the diagnostic accuracy of [(18)F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) with dual-time-point imaging, contrast-enhanced CT (ceCT), and bone scintigraphy (BS) in patients with suspected breast cancer recurrence.

PATIENTS AND METHODS

One hundred women with suspected recurrence of breast cancer underwent 1-hour and 3-hour FDG-PET/CT, ceCT, and BS within approximately 10 days. The study was powered to estimate the precision of the individual imaging tests. Images were visually interpreted using a four-point assessment scale, and readers were blinded to other test results. The reference standard was biopsy along with treatment decisions and clinical follow-up (median, 17 months).

RESULTS

FDG-PET/CT resulted in no false negatives and fewer false positives than the other imaging techniques. Accuracy of results were similar for 1-hour and 3-hour FDG-PET/CT. For distant recurrence, the area under the receiver operating curve was 0.99 (95% CI, 0.97 to 1) for FDG-PET/CT, 0.84 (95% CI, 0.73 to 0.94) for ceCT, and 0.86 (95% CI, 0.77 to 0.94) for the combined ceCT+BS. Of 100 patients, 22 (22%) were verified with distant recurrence, and 18 of these had bone involvement. Nineteen patients (19%) had local recurrence only. In exploratory analyses, diagnostic accuracy of FDG-PET/CT was better than ceCT alone or ceCT combined with BS in diagnosing distant, bone, and local recurrence, shown by a greater area under the receiver operating curve and higher sensitivity, specificity, and superior likelihood ratios.

CONCLUSION

FDG-PET/CT was accurate in diagnosing recurrence in breast cancer patients. It allowed for distant recurrence to be correctly ruled out and resulted in only a small number of false-positive cases. Exploratory findings suggest that FDG-PET/CT has greater accuracy than conventional imaging technologies in this patient group.

The diagnostic value of 18F-FDG PET/CT in association with serum tumor marker assays in breast cancer recurrence and metastasis

Background. After initial treatment of breast cancer (BC), monitoring locoregional recurrence and distant metastases is a great clinical challenge. Objective. To evaluate the efficacy of PET/CT in association with serum tumor makers in BC follow-up. Methods. Twenty-six women with a history of modified radical mastectomy were evaluated by ¹⁸F-FDG PET/CT. The results of PET/CT were compared with those of conventional imaging techniques (CITs) (including mammography, chest radiography, CT, MRI, ultrasound, and bone scintigraphy). Serum tumor markers of CEA, CA 125, and CA 15-3 in the BC patients were also analyzed in association with the results of PET/CT. Results. Compared with CITs, PET/CT was more sensitive to detect the malignant foci and had better patient-based sensitivity and specificity. The mean CA 15-3 serum level was significantly higher in the confirmed positive patients of PET/CT results than in the confirmed negative ones, while there were no significant differences in the serum levels of CEA and CA 125 of both groups. Conclusion. PET/CT is a highly efficient tool for BC follow-up compared with CITs. The high serum levels of CA 15-3 in confirmed positive PET/CT patients indicated the clinical value of CA 15-3 in BC follow-up.

Prognostic impact of 18F-FDG PET/CT staging and of pathological response to neoadjuvant chemotherapy in triple-negative breast cancer

PURPOSE

Mortality is high in patients with locally advanced triple-negative breast cancer (TNBC), especially in those with residual tumour after neoadjuvant chemotherapy (NAC). The aim of this study was to determine if pretreatment (18)F-FDG PET/CT staging and pathological findings after NAC could together allow stratification of patients into prognostic groups.

METHODS

Initial staging with (18)F-FDG PET/CT was performed prospectively in 85 consecutive patients with stage II/III TNBC. Correlations between PET findings and disease-specific survival (DSS) were examined. In patients without distant metastases on PET staging, the impact of pathological response to NAC on DSS was examined. Patterns of recurrence were also analysed.

RESULTS

(18)F-DG PET/CT revealed distant metastases in 11 of 85 patients (12.9 %). Among 74 M0 patients, 23 (31.1 %) showed a pathological complete response (pCR) at surgery, while 51 had residual invasive disease (no pCR). DSS differed considerably among the three groups of patients (log-rank P < .001): among patients with occult metastases on baseline PET/CT, 2-year DSS was 18.2 %, and among patients without initial metastases on PET/CT, 5-year DSS was 61.3 % in patients without pCR after NAC and 95.2 % in those with pCR. Of the 51 patients who did not achieve pCR, 21 relapsed (17 developed distant metastases). The sites of distant recurrence were: lung/pleura (nine patients), brain (eight patients), liver (six patients), distant lymph nodes (six patients) and bone (five patients).

CONCLUSION

In patients with clinical stage II/III TNBC, (18)F-FDG PET/CT findings at initial staging and pathological response at the end of NAC allow three groups of patients with quite different prognoses to be defined. Extraskeletal recurrences predominated. Specific follow-up strategies in patients with TNBC who do not achieve pCR deserve investigation.

Iterative reconstruction using a Monte Carlo based system transfer matrix for dedicated breast positron emission tomography

To maximize sensitivity, it is desirable that ring Positron Emission Tomography (PET) systems dedicated for imaging the breast have a small bore. Unfortunately, due to parallax error this causes substantial degradation in spatial resolution for objects near the periphery of the breast. In this work, a framework for computing and incorporating an accurate system matrix into iterative reconstruction is presented in an effort to reduce spatial resolution degradation towards the periphery of the breast. The GATE Monte Carlo Simulation software was utilized to accurately model the system matrix for a breast PET system. A strategy for increasing the count statistics in the system matrix computation and for reducing the system element storage space was used by calculating only a subset of matrix elements and then estimating the rest of the elements by using the geometric symmetry of the cylindrical scanner. To implement this strategy, polar voxel basis functions were used to represent the object, resulting in a block-circulant system matrix. Simulation studies using a breast PET scanner model with ring geometry demonstrated improved contrast at 45% reduced noise level and 1.5 to 3 times resolution performance improvement when compared to MLEM reconstruction using a simple line-integral model. The GATE based system matrix reconstruction technique promises to improve resolution and noise performance and reduce image distortion at FOV periphery compared to line-integral based system matrix reconstruction.

¹⁸F-FDG-PET/CT in staging, restaging, and treatment response assessment of male breast cancer

PURPOSE

Male breast cancer (BC) is a rare disease, with patterns different from those found in women. Most tumors are detected at more advanced stages than in women. The aim of this study was to analyze the performance of [18F]fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) in staging, restaging, and therapy response assessment.

METHODS

We performed a systematic analysis in the database of Saint-Louis Hospital to identify male patients with BC referred for PET/CT. (18)F-FDG-PET/CT findings considered suspicious for malignancy were compared to biopsy results, further work-up and/or patient follow-up of at least 6 months. Performances of (18)F-FDG-PET/CT were compared to that of conventional imaging (CI) using the McNemar test. The impact of PET/CT on management was evaluated.

RESULTS

During 6 consecutive years, among 12,692 (18)F-FDG-PET/CT oncology studies, 30 were performed in 15 men with BC: 7 examinations for initial staging, 11 for restaging, and 12 for response assessment. Tumors profile was ER+ and one had HER2 overexpression. PET/CT sensitivity, specificity, positive predictive value, negative predictive value and accuracy to detect distant metastases were 100%, 67%, 86%, 100% and 89%, respectively. PET/CT was more informative than CI in 40% of studies (p=0.03; 95% confidence interval: 3.26 - 40%). Findings from (18)F-FDG-PET/CT led to modification in the planned treatment in 13/30 cases (43%).

CONCLUSION

Although all the tumors were ER+, primary lesions and metastases were diagnosed with high sensitivity. (18)F-FDG-PET/CT seems to be a powerful imaging method to perform staging, restaging and treatment response assessment in male patients with BC.

CA15-3 is a useful serum tumor marker for diagnostic integration of hybrid positron emission tomography with integrated computed tomography during follow-up of breast cancer patients

BACKGROUND

The aim of this study was to evaluate the value of CA15-3 for the diagnostic integration of molecular imaging findings performed with hybrid positron emission tomography and computed tomography (PETCT) technology.

METHODS

We retrospectively selected 45 patients with a median age of 60 years (range 39-85 years) and a previous history of breast cancer (BC) who had already been treated with surgery and other treatments. Three measurements of CA15-3 were collected within 1 year before PETCT examination, at 6-9 months 3-6 months and 0-3 months before PETCT. The prolonged clinical outcome or imaging follow-up was used to define disease relapse. An increase in tumor marker value was compared with PETCT findings and disease relapse. Sensitivity and specificity for both tests were calculated with respect to clinical outcome.

RESULTS

Disease relapse was detected in 16 out of 45 BC patients. CA15-3 and PETCT showed 75% sensitivity with a specificity percentage of 76% for CA15-3 and 79% for PETCT. Serum CA15-3 expression levels were significantly higher in BC patients with multiple metastatic sites with hepatic involvement. Analysis of serial CA15-3 serum levels showed an increase in CA15-3 3-6 months before PETCT could identify BC patients at risk for relapse (AUC = 0.81). Moreover, patients receiving anti-hormonal or chemotherapy medications with negative PETCT and positive CA15-3 relapsed after a median time of 158 days compared to patients who were negative for both tests and who were free from disease for at least 1 year.

CONCLUSIONS

Our results showed that serial increases in CA15-3 can be used to predict positive PETCT results in BC patients during follow-up. Increased levels of CA15-3 may be considered an early warning sign in patients needing accurate molecular imaging investigations, as they are at higher risk of recurrence. In cases of elevated levels, multiple lesions or liver involvement may exist. Also, patients receiving chemotherapeutic or anti-hormonal treatment who have negative PETCT scans and increased CA15-3 serum levels should be considered at risk for relapse, because the CA15-3-linked biochemical signal of the presence of a tumor can predict positive metabolic imaging.

Current approaches and challenges in early detection of breast cancer recurrence

Early detection of breast cancer recurrence is a key element of follow-up care and surveillance after completion of primary treatment. The goal is to improve survival by detecting and treating recurrent disease while potentially still curable assuming a more effective salvage surgery and treatment. In this review, we present the current guidelines for early detection of recurrent breast cancer in the adjuvant setting. Emphasis is placed on the multidisciplinary approach from surgery, medical oncology, and radiology with a discussion of the challenges faced within each setting.

Future directions for the early detection of recurrent breast cancer

The main goal of follow-up care after breast cancer treatment is the early detection of disease recurrence. In this review, we emphasize the multidisciplinary approach to this continuity of care from surgery, medical oncology, and radiology. Challenges within each setting are briefly addressed as a means of discussion for the future directions of an effective and efficient surveillance plan of post-treatment breast cancer care.

FDG avidity at PET/CT during adjuvant hormonal therapy in patients with breast cancer

BACKGROUND

We aim to retrospectively evaluate the impact of hormone therapy (HT) on FDG avidity of metastatic lesions in patients with breast cancer (BC) undergoing PET/CT.

PATIENTS AND METHODS

Three hundred eight patients with BC were scanned with PET/CT at 2 Italian institutions (mean time from diagnosis 4 yrs, range: 1-24 yrs). Main indications for PET/CT were elevation of tumor markers (34.4%) and clinical or radiological suspicion of relapse (65.6%). The diagnostic accuracy of FDG PET/CT was computed according to the standard method. Student t test was used to assess the mean differences between the study groups, whereas categorical data were compared with chi-square test. Significance was set at P <0.05.

RESULTS

Two hundred sixty-four patients with positive estrogen receptor and who had received adjuvant HT were included in the analysis. At the time of PET/CT scan, HT was ongoing in 176 patients (66.7%) and 88 (33.3%) had completed adjuvant HT. Ninety-eight (55.7%) patients on HT and 59 (67%) off HT had a positive PET/CT; therefore, the scan resulted negative in the remaining 107 patients, 78 and 29 on and off HT, 44.3% and 33%, respectively (P < 0.001). At a median follow-up of 7 months (range 1-48 mos), disease recurrence was confirmed in either clinical or radiological examinations in 126 (47.7%) patients; 72 (40.9%) versus 54 (61.4%) patients on and off HT, respectively (P < 0.005). True-positive PET/CT results were found in 82% and 91% of patients on and off HT, respectively, whereas it failed to identify disease relapse in 13 (18%) and 5 (9%) patients on and off HT, respectively.

CONCLUSIONS

In our series, FDG PET/CT shows a similar diagnostic accuracy in detecting disease relapse between patients with BC on adjuvant HT versus those who have completed therapy. These preliminary results suggest that the glucose metabolism is not altered by hormonal suppression at the time of the scan.

Role of positron emission tomography/computed tomography in breast cancer

Although positron emission tomography (PET) imaging may not be used in the diagnosis of breast cancer, the use of PET/computed tomography is imperative in all aspects of breast cancer staging, treatment, and follow-up. PET will continue to be relevant in personalized medicine because accurate tumor status will be even more critical during and after the transition from a generic metabolic agent to receptor imaging. Positron emission mammography is an imaging proposition that may have benefits in lower doses, but its use is limited without new radiopharmaceuticals.

Clinical application of 18F-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography in breast cancer

Positron emission tomography (PET)/computed tomography (CT) is not suited for primary diagnostics of breast tumours and it cannot replace sentinel lymph node technique in determining metastases to the axilla. PET/CT has a high sensitivity and specificity regarding the detection of loco-regional recurrence and metastases to mediastinal and internal mammary lymph nodes, as well as distant metastases. Whether the method can replace conventional methods, or be a supplement when this is non-conclusive, remains unresolved. PET/CT cannot be recommended for routine follow-up but is recommended in patients with suspected relapse when conventional imaging has given equivocal results. PET/CT can be applied to confirm isolated loco-regional relapse or metastatic lesion detected by conventional imaging. PET/CT has a high sensitivity for detecting response to treatment, but a low specificity calls for cautions. Further investigations into the use of PET/CT to predict and monitor response are warranted, before this approach may find its way into a clinical setting. In the future, PET/CT will probably find increasing use in treatment planning and evaluation of patients with breast cancer.

Usefulness of traditional serum biomarkers for management of breast cancer patients

The measurement of serum tumor markers levels in breast cancer (BC) patients is an economic and noninvasive diagnostic assay frequently requested by clinical oncologists to get information about the presence or absence of disease as well as its evolution. Despite their wide use in clinical practice, there is still an intense debate between scientific organizations about the real usefulness for patient monitoring during followup as well as response to therapy evaluation in case of advanced BC. In this review, we want to highlight the current recommendations published by scientific organizations about the use of “established” BC serum markers (CEA, TPA, TPS, CIFRA-21, CA15-3, and s-HER2) in clinical oncology practice. Moreover, we will focus on recent papers evidencing the usefulness of tumor markers levels measurement as a guide for the prescription and diagnostic integration of molecular imaging exams such as those performed by hybrid 18-fluorofeoxyglucose-positron emission tomography with integrated computed tomography. This technology is nowadays able to detect early cancer lesions undetectable by conventional morphological imaging investigation and most likely responsible for increasing of serum tumor markers levels.

Doppler ultrasonography reveals blood flow signals within the masses of invasive moles in subjects with normal hCG levels after chemotherapy: Three case reports

A consensus has formed that patients with invasive moles should continue with one to three cycles of chemotherapy after human chorionic gonadotropin (hCG) levels have decreased to a normal level. However, the management plan has not been agreed for cases where Doppler ultrasonography (DU) indicates blood-flow signals within the tumor mass after one to three cycles of chemotherapy when the hCG concentration has returned to normal. The present study describes the clinical and therapeutic courses of three patients with invasive moles with confirmed blood-flow signals (by DU) after their hCG levels had normalized. One patient underwent surgery to remove the mass within the uterine muscle, while the other two patients decided to cease chemotherapy and were managed by follow-up appointments; all three patients had good outcomes. These data illustrate that patients with invasive moles should be followed up if DU indicates blood-flow signals in the tumor mass after one to three cycles of chemotherapy when the hCG level has decreased back to a normal level.

(18)F-FDG PET/CT-positive internal mammary lymph nodes: pathologic correlation by ultrasound-guided fine-needle aspiration and assessment of associated risk factors

OBJECTIVE

Metastatic breast cancer in internal mammary (IM) lymph nodes is associated with a poor prognosis. This study correlates (18)F-FDG PET/CT-positive IM lymph nodes with ultrasound-guided fine-needle aspiration (FNA) cytopathologic results and determines risk factors for IM node positivity on PET/CT.

MATERIALS AND METHODS

For this retrospective study, a database search was performed to identify patients referred for whole-body (18)F-FDG PET/CT for initial staging or restaging of breast cancer from January 1, 2005, through December 31, 2010. The radiology reports and images were reviewed for patients with (18)F-FDG-avid IM lymph nodes on PET/ CT and correlated with the cytopathologic results from FNA of selected PET/CT-positive IM lymph nodes. The patients with positive IM nodes on PET/CT who underwent PET/CT for initial staging were compared against age-matched and tumor size-matched patients to identify risk factors for IM node positivity on PET/CT.

RESULTS

One hundred ten of 1259 patients (9%) had an (18)F-FDG-avid IM lymph node on PET/CT. Twenty-five patients underwent ultrasound-guided FNA of a suspicious IM node, and 20 IM lymph nodes (80%) were cytologically proven metastases from the primary breast malignancy. High tumor grade, the presence of lymphovascular invasion (LVI), and triple receptor-negative hormonal receptor status were found to be significant risk factors for IM node positivity on PET/CT (p < 0.05).

CONCLUSION

Although fewer than 10% of breast cancer patients have positive IM nodes on (18)F-FDG PET/CT performed for initial staging or restaging, a positive IM node indicates a very high likelihood of malignant involvement on ultrasound-guided FNA. The presences of high tumor grade, LVI, or triple receptor-negative status are risk factors for IM node positivity on (18)F-FDG PET/CT.

Is a comparative clinical trial for breast cancer tumor markers to monitor disease recurrence warranted? A value of information analysis

BACKGROUND

Breast cancer tumor markers are used by some clinicians to screen for disease recurrence risk. Since there is limited evidence of benefit, additional research may be warranted.

AIM

To assess the potential value of a randomized clinical trial of breast tumor marker testing in routine follow-up of high-risk, stage II-III breast cancer survivors.

MATERIALS & METHODS

We developed a decision-analytic model of tumor marker testing plus standard surveillance every 3-6 months for 5 years. The expected value of sample information was calculated using probabilistic simulations and was a function of: the probability of selecting the optimal monitoring strategy with current versus future information; the impact of choosing the nonoptimal strategy; and the size of the population affected.

RESULTS

The value of information for a randomized clinical trial involving 9000 women was US$214 million compared with a cost of US$30-60 million to conduct such a trial. The probability of making an alternate, nonoptimal decision and choosing testing versus no testing was 32% with current versus future information from the trial. The impact of a nonoptimal decision was US$2150 and size of population impacted over 10 years was 308,000. The value of improved information on overall survival was US$105 million, quality of life US$37 million and test performance US$71 million.

CONCLUSION

Conducting a randomized clinical trial of breast cancer tumor markers appears to offer a good societal return on investment. Retrospective analyses to assess test performance and evaluation of patient quality of life using tumor markers may also offer valuable areas of research. However, alternative investments may offer even better returns in investments and, as such, the trial concept deserves further study as part of an overall research-portfolio evaluation.