PET/CT for Patients With Breast Cancer: Where Is the Clinical Impact?

OBJECTIVE. FDG PET/CT affects the management of patients with breast cancer in multiple settings, including initial staging, treatment response assessment, and evaluation of suspected recurrence. This article reviews the strengths and weaknesses of FDG PET/CT for the staging of the primary breast lesion, axillary and extraaxillary nodal metastases, and distant metastases. The utility of FDG PET/CT for measuring breast cancer treatment response is appraised and compared with other imaging modalities. The role that tumor histologic type may have on PET/CT interpretation is also discussed. CONCLUSION. Although FDG PET/CT is currently the PET modality with the greatest effect on clinical management of patients with breast cancer, novel radiotracers and imaging systems continue to broaden the application of PET for patients with breast cancer. National Comprehensive Cancer Network guidelines for FDG PET/CT for patients with breast cancer are reviewed. Emphasis is given where FDG PET/CT has shown clinical effect.

The value of 18F-FDG PET/CT imaging in breast cancer staging.

The National Comprehensive Cancer Network (NCCN) guidelines recommend assessment with positron emission tomography with 2-deoxy-2-[fluorine-18]fluoro-D-glucose integrated with computed tomography (18F-FDG PET/CT) in staging of breast cancer, starting from the stage IIIA. Previously, PET/CT contributed to the accurate staging from the stage IIB. Our aim is to evaluate the contribution of 18F-FDG PET/CT in staging of breast cancer patients. A total of 234 patients were retrospectively evaluated. PET/CT was performed preoperatively in 114/234 and postoperatively in 120/234 patients. Initial staging was performed based on histopathological results in 125/234 and clinical results in 109/234 patients, according to the American Joint Committee on Cancer (AJCC) classification. All patients had a normal abdominal ultrasound and chest x-ray. Following PET/CT imaging, modification in the staging was performed in patients with the metastatic findings. In 42/234 (17.9%) patients hypermetabolic extra-axillary regional lymph nodes and in 65/234 patients (27.7%) distant metastatic involvement were detected with PET/CT. Modification in the staging was applied in 82/234 (35%) patients. Patient management was changed in 69/234 (29.4%) cases. The percentage of patients with upstaging, according to each stage, was as follows: IIA: 18.6%, IIB: 30%, IIIA: 46.3%, IIIB: 68.8%, and IIIC: 20.8%. In 43/43 patients, 99mTc-methylene diphosphonate (MDP) bone scan did not show additional bone metastasis. In 5/32 patients, metastatic involvement was detected with sentinel lymph node biopsy (SLNB), but preoperative PET/CT scan did not reveal hypermetabolic lymph nodes. Although our study was limited by the referral bias and lack of homogeneity in the referral group, PET/CT still significantly contributed to the accurate staging and management of our breast cancer patients, starting from the stage IIA.

Upper Extremity Lymphedema After Axillary Lymph Node Dissection: Prospective Lymphoscintigraphic Evaluation.

This prospective study was designed to evaluate changes in upper extremity lymphatic drainage after ALND in comparison to the preoperative status using lymphoscintigraphy. The study enrolled 44 women (mean age: 57.95; range: 35-80) with a new diagnosis of unilateral invasive breast carcinoma who had been scheduled to undergo ALND. This was a substudy of the physiotherapeutic project, in which subjects after ALND were randomized into 4 groups treated with: 1) rehabilitation exercises; 2) manual lymphatic drainage; 3) pneumatic compression pump; and 4) education only. Clinical evaluation which included arm measurements and lymphoscintigraphy was performed in every subject before surgery and 3 times after surgery (1-6 weeks, 1 and 2 years after ALND). Follow-up was completed in 44 subjects at 1 year and in 32 subjects at 2 years. Lymphedema diagnosis was made in 4 subjects 1 year after ALND (9%) and in 8 subjects 2 years after ALND (25%). Among them, respectively, only 50% and 62% noticed and reported lymphedema. Quantitative analysis of lymphoscintigrams and photoplethysmography results did not reveal upper extremities lymphatic transport and/or venous function impairment after the ALND procedure. Qualitative analysis of lymphoscintigrams revealed most commonly disappearance of previously functional lymph nodes and appearance of dermal backflow in subjects who developed lymphedema. Conversely, appearance of functional lymph nodes in different locations after ALND may indicate protection from development of upper extremity lymphedema.

Transition from nerve stimulator to sonographically guided axillary brachial plexus anesthesia in hand surgery: block quality and patient satisfaction during the transition period.

OBJECTIVES: Sonographic guidance for peripheral nerve anesthesia has proven increasingly successful in clinical practice; however, fears that a change to sonographically guided regional anesthesia may impair the block quality and operating room work flow persist in certain units. In this retrospective cohort study, block quality and patient satisfaction during the transition period from nerve stimulator to sonographic guidance for axillary brachial plexus anesthesia in a tertiary referral center were investigated. METHODS: Anesthesia records of all patients who had elective surgery of the wrist or hand during the transition time (September 1, 2006-August 25, 2007) were reviewed for block success, placement time, anesthesiologist training level, local anesthetic volume, and requirement of additional analgesics. Postoperative records were reviewed, and patient satisfaction was assessed by telephone interviews in matched subgroups. RESULTS: Of 415 blocks, 341 were sonographically guided, and 74 were nerve stimulator guided. Sonographically guided blocks were mostly performed by novices, whereas nerve stimulator-guided blocks were performed by advanced users (72.3% versus 14%; P < .001). Block performance times and success rates were similar in both groups. In sonographically guided blocks, significantly less local anesthetics were applied compared to nerve stimulator-guided blocks (mean ± SD, 36.1 ± 7.1 versus 43.9 ± 6.1 mL; P< .001), and less opioids were required (fentanyl, 66.1 ± 30 versus 90 ± 62 µg; P< .001). Interviewed patients reported significantly less procedure-related discomfort, pain, and prolonged procedure time when block placement was sonographically guided (2% versus 20%; P = .002). CONCLUSIONS: Transition from nerve stimulator to sonographic guidance for axillary brachial plexus blocks did not change block performance times or success rates. Patient satisfaction was improved even during the early institutional transition period.

Proximal humeral fractures: the role of calcium sulphate augmentation and extended deltoid splitting approach in internal fixation using locking plates.

UNLABELLED: The aim of our study is to analyse the results of our surgical technique for the treatment of proximal humeral fractures and fracture dislocations using locking plates in conjunction with calcium sulphate bone-substitute augmentation and tuberosity repair using high-strength sutures. We used the extended deltoid-splitting approach for fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations. Optimal surgical management of proximal humeral fractures remains controversial. Locking plates have become a popular method of fixation. However, failure of fixation may occur if they are used as the sole method of fixation in comminuted fractures, especially in osteopenic bone. METHODS: We retrospectively analysed 22 proximal humeral fractures in 21 patients; 10 were male and 11 female with an average age of 64.6 years (range 37-77). Average follow-up was 24 months. Eleven of these fractures were exposed by the extended deltoid-splitting approach. Fractures were classified according to Neer and Hertel systems. Preoperative radiographs and computed tomography (CT) scans in three- and four-part fractures were done to assess the displacement and medial calcar length for predicting the humeral head vascularity. According to the Neer classification, there were five two-part, six three-part, five four-part fractures and six fracture-dislocations (two anterior and four posterior). Results were assessed clinically with disabilities of the arm, shoulder and hand (DASH) scores, modified Constant and Murley scores and serial postoperative radiographs. RESULTS: The mean DASH score was 16.18 and the modified Constant and Murley score was 64.04 at the last follow-up. Eighteen out of twenty-two cases achieved good clinical outcome. All the fractures united with no evidence of infection, failure of fixation, malunion, tuberosity failure, avascular necrosis or adverse reaction to calcium sulphate bone substitute. There was no evidence of axillary nerve injury. Four patients had a longer recovery period due to stiffness, associated wrist fracture and elbow dislocation. The CaSO4 bone substitute was replaced by normal appearing trabecular bone texture at an average of 6 months in all patients. CONCLUSION: In our experience, we have found the use of locking plates, calcium sulphate bone substitute and tuberosity repair with high-strength sutures to be a safe and reliable method of internal fixation for complex proximal humeral fractures and fracture-dislocations. Furthermore, we have also found the use of the extended deltoid-splitting approach to be safe and to provide excellent exposure facilitating accurate reduction for fixation of the fracture patterns involving displacement of both lesser and greater tuberosities and for fracture-dislocations.

Sentinel lymph node biopsy for local recurrence of breast cancer after breast-conserving therapy.

BACKGROUND: Lymphatic mapping (LM) with sentinel lymph node (SLN) biopsy has revolutionized the surgical staging of primary breast cancer, but its utility and feasibility have not been established in patients with ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) and radiation. METHODS: We reviewed our breast cancer database to identify all patients who underwent preoperative lymphoscintigraphy for IBTR and whose primary tumor had been managed by BCS, SLN biopsy and/or axillary node dissection, and adjuvant breast irradiation. RESULTS: Preoperative lymphoscintigraphy identified migration to the regional nodal drainage basins in 11 (73%) of 15 patients, as follows: 5 ipsilateral axillary, 1 supraclavicular, 2 internal mammary, 2 interpectoral, and 3 contralateral axillary. Two patients demonstrated drainage to two nodal basins. In four patients, no drainage was observed. Intraoperative LM with radioisotope plus blue dye identified at least 1 SLN in 11 of 14 patients, and histopathologic evaluation revealed metastasis in 3 patients (2 contralateral axillary and 1 ipsilateral axillary). During preoperative lymphoscintigraphy, the radiocolloid migration time tended to be longer and the drainage pathways more variable than those associated with primary tumors. CONCLUSIONS: LM/SLN biopsy can be successfully performed in patients with IBTR after prior BCS, axillary surgical staging, and adjuvant radiation. This approach illustrates variations in the lymphatic drainage of recurrent breast tumors and may permit the identification of regional metastasis not noted with conventional imaging techniques.