Role of FDG PET-CT in evaluation of locoregional nodal disease for initial staging of breast cancer

Abstract

Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is not indicated or recommended in the initial staging of early breast cancer. Although it is valuable for detecting distant metastasis, providing prognostic information, identifying recurrence and evaluating response to chemotherapy, the role of FDG PET/CT in evaluating locoregional nodal status for initial staging of breast cancer has not yet been well-defined in clinical practice. FDG PET/CT has high specificity but compromised sensitivity for identifying axillary nodal disease in breast cancer. Positive axillary FDG PET/CT is a good predictor of axillary disease and correlates well with sentinel lymph node biopsy (SLNB). FDG PET/CT may help to identify patients with high axillary lymph node burden who could then move directly to axillary lymph node dissection (ALND) and would not require the additional step of SLNB. However, FDG PET/CT cannot replace SLNB or ALND due to unsatisfactory sensitivity. The spatial resolution of PET instruments precludes the detection of small nodal metastases. Although there is still disagreement regarding the management of internal mammary node (IMN) disease in breast cancer, it is known that IMN involvement is of prognostic significance, and IMN metastasis has been associated with higher rates of distant metastasis and lower overall survival rates. Limited clinical observations suggested that FDG PET/CT has advantages over conventional modalities in detecting and uncovering occult extra-axillary especially IMN lesions with upstaging the disease and an impact on the adjuvant management.

Keywords: Breast cancer, Fluorodeoxyglucose positron emission tomography/computed tomography, Locoregional nodal disease, Axillary lymph node, Internal mammary lymph node, Axillary lymph node dissection, Sentinel lymph node biopsy

Core tip: The presence and extent of locoregional nodal metastasis at diagnosis is the single most important prognostic factor in breast cancer. The predominant lymphatic drainage pathway from the breast cancer is toward the axilla. Fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) is a good predictor of axillary disease and correlates well with sentinel lymph node biopsy (SLNB). FDG PET/CT may help to identify patients with high axillary lymph node burden who could then move directly to axillary lymph node dissection (ALND) and would not require the additional step of SLNB. However, FDG PET/CT cannot replace SLNB or ALND due to unsatisfactory sensitivity secondary to the limitation of its spatial resolution. The internal mammary node (IMN) involvement is of prognostic significance in breast cancer, and IMN metastasis has been associated with higher rate of distant metastasis and lower overall survival rates. Limited preliminary data indicated that FDG PET/CT plays a role in identification of positive IMN, and it is superior to conventional imaging modalities.