Clinical implications of non-breast cancer related findings on FDG-PET/CT scan prior to neoadjuvant chemotherapy in patients with breast cancer.

PURPOSE: Breast cancer (BC) patients undergoing FDG-PET/CT scans for neoadjuvant chemotherapy (NAC) may have additional non-BC related findings. The aim of this study is to describe the clinical implications of these findings. METHODS: We included BC patients who underwent an FDG-PET/CT scan in our institute between 2011-2020 prior to NAC. We focused on patients with an additional non-BC related finding (i.e. BC metastases were excluded) for which diagnostic work-up was performed. Information about the diagnostic work-up and the clinical consequences was retrospectively gathered. A revision of all FDG-PET/CT scans was conducted by an independent physician to assess the suspicion level of the additional findings. RESULTS: Of the 1337 patients who underwent FDG-PET/CT, 202 patients (15%) had an non-BC related additional finding for which diagnostic work-up was conducted, resulting in 318 examinations during the first year. The non-BC related findings were mostly detected in the endocrine region (26%), gastro-intestinal region (16%), or the lungs (15%). Seventeen patients (17/202: 8%, 17/1337: 1.3%) had a second primary malignancy. Only 8 patients (8/202: 4%, 8/1337: 0.6%) had a finding that was considered more prognosis-determining than their BC disease. When revising all FDG-PET/CT scans, 57 (202/57: 28%) of the patients had an additional finding categorized as low suspicious, suggesting no indication for diagnostic work-up. CONCLUSION: FDG-PET/CT scans used for dissemination imaging in BC patients detect a high number of non-BC related additional findings, often clinically irrelevant and causing a large amount of unnecessary work-up. However, in 8% of the patients undergoing diagnostic work-up for an additional finding, a second primary malignancy was detected, warranting diagnostic attention in selected patients.

The efficacy of screening with FDG-PET/CT for distant metastases in breast cancer patients scheduled for neoadjuvant systemic therapy.

PURPOSE: This study aims to identify which breast cancer patients benefit from the routine use of FDG-PET/CT in a large cohort of patients scheduled for neoadjuvant systemic therapy (NST). METHODS: A total of 1337 breast cancer patients eligible for NST were identified from a retrospective database between 2011 and 2020 at a single tertiary care hospital. All patients underwent staging with FDG-PET/CT prior to NST. The incidence and extent of asymptomatic distant metastases in different patient subgroups were determined, as well as the impact on treatment. Logistic regression analysis was used to identify prognostic patient and tumor characteristics. RESULTS: FDG-PET/CT detected distant metastases in 109 patients (8%). Initial clinical stage was a prognostic factor for the presence of distant metastases, with a significantly higher risk for stage 2b and 3 as opposed to lower stages (p < 0.001). The incidence of distant metastases was 3% (4/125) for stage 1, 2% (8/534) for stage 2a, 7% (24/354) for stage 2b and 23% (73/324) for stage 3. Other characteristics such as age, tumor subtype, histological type and grade were not correlated with the risk of distant metastases. Among the subset of patients with distant metastases, 46% received palliative treatment, while the remaining 54% were diagnosed with oligometastatic breast cancer and were treated with curative intent. CONCLUSION: The results of the current study support the routine use of FDG-PET/CT for the detection of distant metastases in breast cancer patients with initial clinical stage 2b and 3, regardless of tumor subtype.

Cosmetic outcome in patients with early stage breast cancer after accelerated partial breast irradiation using intraoperative or external beam radiotherapy.

Purpose: The aim of this study is to evaluate the cosmetic outcome among early stage breast cancer patients who underwent accelerated partial breast irradiation with either intraoperative electron radiotherapy (IOERT) or photon external beam radiotherapy (EB-APBI). Materials and methods: This prospective multicenter cohort study enrolled women aged 60 years and older who underwent breast-conserving therapy. Following breast-conserving surgery, patients were treated with either IOERT or EB-APBI. Cosmetic outcome was evaluated over a 5 year follow-up period using both subjective scoring by patients and physicians, as well as objective scoring using BCCT.core software. Differences between treatments over time were described with mixed model analyses. Results: A total of 241 patients treated with IOERT and 164 patients treated with EB-APBI were eligible for cosmetic analysis. In both groups, the majority of patients reported a satisfactory cosmetic outcome, with no significant differences between treatments over time (p = 0.538). This was also observed by physicians, with satisfactory outcomes ranging from 94 % (170/181) to 91 % (69/76) over time in the IOERT group and from 93 % (124/133) to 95 % (54/57) in the EB-APBI group (p = 0.579). BCCT.core analysis returned satisfactory cosmetic outcomes in 75 % (54/72) of the IOERT patients at 3 years and in 77 % (20/26) at 5 years. These numbers were 86 % (72/84) and 90 % (36/40) for the EB-APBI patients, with no significant differences between treatment over time (p = 0.834). Conclusion: Regarding the cosmetic results, IOERT and EB-APBI yield comparable and satisfactory outcomes over 5 years follow-up in the treatment of early stage breast cancer.

The Impact of Percutaneous Coronary Intervention on Mortality in Patients With Coronary Lesions Who Underwent Transcatheter Aortic Valve Replacement.

OBJECTIVES: To analyze the effect of percutaneous coronary intervention (PCI) before transcatheter aortic valve replacement (TAVR) on all-cause and cardiovascular mortality after TAVR, differentiating between significant proximal lesions and the non-proximal (residual) lesions. METHODS: An institutional TAVR database was complemented with data on the extent of coronary artery disease (CAD), lesion location, lesion severity, and the location of PCI. Survival analysis was performed to investigate the impact on 6-month and 3-year mortality after TAVR in all patients and in subgroups of patients with significant proximal lesions (>70% diameter stenosis [DS], >50% DS in left main), the non-proximal residual lesions, and in a propensity score matched cohort. RESULTS: Among the 577 included patients, mean age was 83 years, 50% were female, and 31% had diabetes mellitus. Preprocedural PCI of unselected lesions was independently associated with increased 6-month mortality (hazard ratio, 2.2; 95% confidence interval, 1.0-4.6; P=.04), but selective PCI of significant proximal lesions did not have an association with higher mortality, nor did we find a significant effect of PCI on mortality in the propensity-matched cohort. CONCLUSION: Routine pre-TAVR PCI is not associated with mortality reduction in TAVR patients with coronary lesions in any segment or in patients with proximal coronary lesions. Despite the lack of a beneficial effect of routine pre-TAVR PCI, we cannot exclude a beneficial effect in a selection of patients with proximal lesions. Therefore, we strongly support the current clinical guidelines to only consider pre-TAVR PCI in proximal coronary lesions, while advocating a restrictive pre-TAVR PCI strategy.