18F-FDG PET/CT in Staging Patients with Locally Advanced or Inflammatory Breast Cancer: Comparison to Conventional Staging

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FIGURE 1.
Study flow diagram. US = ultrasonography.
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FIGURE 2.
Bone scan (A) and PET/CT (B) findings in patient with clinical T4bN0 (stage IIIB), estrogen receptor–positive, progesterone receptor–positive, HER2-negative, grade 3 invasive ductal carcinoma of right breast. PET/CT showed primary tumor and depicted lytic metastasis of vertebral body of L3. MR imaging confirmed bone metastasis (not shown). Bone scanning was falsely negative (slight heterogeneity of upper border of L3 was considered suggestive of arthrosis).
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FIGURE 3.
Bone scan (A) and PET/CT (B) findings in patient with clinical T4bN3 (stage IIIC) estrogen receptor–positive, progesterone receptor–negative, HER2-negative, grade 3 invasive ductal carcinoma of left breast. PET/CT showed locally advanced primary breast cancer with axillary and supraclavicular lymph nodes, as well as numerous distant metastases to bones and pleura. Bone scanning was true-positive, showing faint uptake at lower part of left sacroiliac joint.
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FIGURE 4.
Kaplan–Meier disease-specific survival for 104 patients with adequate follow-up.

TABLE 1

Patients and Tumor Characteristics

Characteristic	No. of patients (of 117 total)
Noninflammatory LABC^*	82 (70)
T1 N2 M0	1 (1)
T1 N3 M0	2 (2)
T2 N2 M0	11 (9)
T2 N3 M0	1 (1)
T3 N2 M0	14 (12)
T3 N3 M0	5 (4)
T4a/b/c N0 M0	13 (11)
T4a/b/c N1 M0	20 (18)
T4a/b/c N2 M0	12 (10)
T4a/b/c N3 M0	3 (3)
Inflammatory breast cancer^*	35 (30)
T4d N0 M0	1 (1)
T4d N1 M0	16 (14)
T4d N2 M0	12 (10)
T4d N3 M0	6 (5)
Tumor type
Invasive ductal carcinoma	98 (84)
Invasive lobular carcinoma	12 (10)
Other	7 (6)
Grade
Grade 1	2 (2)
Grade 2	49 (42)
Grade 3	58 (49)
Unspecified	8 (7)
Estrogen receptor status^†
Positive	59 (50)
Negative	57 (49)
Unspecified	1 (1)
Progesterone receptor status^†
Positive	28 (24)
Negative	87 (75)
Unspecified	1 (1)
HER2 status^‡
Positive	22 (19)
Negative	94 (80)
Unspecified	1 (1)

↵* Clinical classification before PET/CT and conventional distant work-up.
↵† Tumors were considered positive for ER or for PR if >10% of cells showed staining by immunohistochemistry.
↵‡ Tumors were considered to overexpress c-erbB-2 oncoprotein (HER2-positive) if >30% of invasive tumor cells showed definite membrane staining resulting in so-called fishnet appearance.
Data in parentheses are percentages.

TABLE 2

Findings with ¹⁸F-FDG PET/CT in 3 Different Groups

Results expressed on per-patient basis	Noninflammatory LABC	Inflammatory breast cancer	Whole population
Patients	82 (70)	35 (30)	117 (100)
Overall stage modifications^*	39 (48)	22 (63)	61 (52)
Lymph nodes^† outside level I and level II axillary levels	27 (33)	22 (63)	49 (42)
Internal mammary node involvement	12 (15)	10 (28)	22 (19)
Infraclavicular	19 (23)	15 (43)	34 (29)
Supraclavicular	13 (16)	13 (37)	26 (22)
Distant metastases^‡	27 (33)	16 (46)	43 (37)
Bone	20 (24)	10 (29)	30 (26)
Lung	3 (4)	3 (9)	6 (5)
Pleura	2 (2)	0	2 (2)
Distant lymph nodes^§	11 (13)	8 (23)	19 (16)
Liver	6 (7)	4 (11)	10 (8)
Second cancer	0	2 (6)	2 (2)

↵* Some women had extraaxillary lymph nodes as well as distant metastases.
↵† Some women had lymph node metastases in different areas.
↵‡ Some women had distant metastases in different viscera.
↵§ Distant lymph nodes were cervical, mediastinal, hilar, contralateral axillary, or abdominopelvic.
Data are n, with percentages in parentheses.

TABLE 3

Performance of PET/CT Versus Conventional Imaging Work-up to Depict Distant Metastases in Overall Series

Site	PET/CT	Bone scanning	Chest imaging (radiography or dedicated CT)	Abdominal imaging (sonography or enhanced CT)	Total^*
Bone metastases	30	23^†	—	—	30
Lung metastases	6^‡	—	7	—	7
Pleura	2	—	1	—	2
Distant lymph node metastases	19	—	10^§	1	19
Liver metastases	10	—	—	9^║	10

↵† 19 positive bone scans and 4 suggestive nonequivocal bone scans.
↵* In total, 43 patients had distant metastases. Some women had metastases in different viscera.
↵‡ Two women with lung metastases had no ¹⁸F-FDG uptake; metastases were detected only on CT part of PET/CT imaging.
↵§ Among 19 patients with lymph node metastases detected by PET/CT, 18 were positive in supradiaphragmatic area. All these patients had chest radiography, and 13 had dedicated chest CT.
↵║ Among 10 patients with liver metastases, 7 had liver sonography and 8 had abdominal enhanced CT.
Data are expressed per patient (not per lesion).