title: Assessment of axillary lymph node involvement in breast cancer patients with positron emission tomography using radiolabeled 2-(fluorine-18)-fluoro-2-deoxy-D-glucose.
abstract: BACKGROUND
  The presence of metastatic tumor cells in the axillary lymph nodes is an important factor when deciding whether or not to treat breast cancer patients with adjuvant therapy. Positron emission tomography (PET) imaging with the radiolabeled glucose analogue 2-(fluorine-18)-fluoro-2-deoxy-D-glucose (F-18 FDG) has been used to visualize primary breast tumors as well as bone and soft-tissue metastases.
  
  
  OBJECTIVE
  This study was undertaken to evaluate before surgery the diagnostic accuracy of PET for detection of axillary lymph node metastases in patients suspected of having breast cancer.
  
  
  METHODS
  Women who were scheduled to undergo surgery for newly discovered, suspected breast cancers were referred for PET imaging of the axilla region. The women were first clinically examined to determine the status of their axillary lymph nodes (i.e., presence or absence of metastases). Fifty-one women were intravenously administered F-18 FDG and were studied by PET imaging. Attenuation-corrected transaxial and coronal images were visually evaluated by two nuclear medicine physicians (blinded to the patient's medical history) for foci of increased F-18 FDG uptake in the axilla region. All patients underwent surgery for their suspected breast cancers. Axillary lymph node dissection was also performed on all patients with breast cancer, with the exception of four patients who received primary chemotherapy for locally advanced breast cancer. A single pathologist analyzed breast tumor and lymph node tissue specimens.
  
  
  RESULTS
  The overall sensitivity (i.e., the ability of the test to detect disease in patients who actually have disease) and specificity (i.e., the ability of the test to rule out disease in patients who do not have disease) of this method for detection of axillary lymph node metastases in these patients were 79% and 96%, respectively. When only patients with primary breast tumors larger than 2 cm in diameter (more advanced than stage pT1; n = 23) were considered, the sensitivity of axillary PET imaging increased to 94%, and the corresponding specificity was 100%. Lymph node metastases could not be identified in four of six patients with small primary breast cancers (stage pT1), resulting in a sensitivity of only 33%. Axillary PET imaging provided additional diagnostic information in 12 (29%) of 41 breast cancer patients with regard to the extension of disease to other sites (i.e., other lymph nodes, skin, bone, and lung).
  
  
  CONCLUSIONS
  PET imaging with F-18 FDG allowed accurate and noninvasive detection of axillary lymph node metastases, primarily in patients with breast cancer more advanced than stage pT1. Detection of micrometastases and small tumor-infiltrated lymph nodes is limited by the currently achievable spatial resolution of PET imaging.
  
  
  CONCLUSIONS
  In clinical practice, PET imaging cannot substitute for histopathologic analysis in detecting axillary lymph node metastases in breast cancer patients. PET imaging, however, improves the preoperative staging of the disease in breast cancer patients and, therefore, might alter therapeutic regimen options.
authors.affiliation: Department of Nuclear Medicine, Technische Universität München, Federal Republic of Germany.
authors.forename: N
authors.initials: N
authors.lastname: Avril
authors.forename: J
authors.initials: J
authors.lastname: Dose
authors.forename: F
authors.initials: F
authors.lastname: Jänicke
authors.forename: S
authors.initials: S
authors.lastname: Ziegler
authors.forename: W
authors.initials: W
authors.lastname: Römer
authors.forename: W
authors.initials: W
authors.lastname: Weber
authors.forename: M
authors.initials: M
authors.lastname: Herz
authors.forename: W
authors.initials: W
authors.lastname: Nathrath
authors.forename: H
authors.initials: H
authors.lastname: Graeff
authors.forename: M
authors.initials: M
authors.lastname: Schwaiger
mesh_terms: D000328:Adult; D000368:Aged; D001365:Axilla / Q000000981:diagnostic imaging*; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*; D003847:Deoxyglucose / Q000031:analogs & derivatives*; D005260:Female; D005462:Fluorine Radioisotopes; D019788:Fluorodeoxyglucose F18; D006801:Humans; D008207:Lymphatic Metastasis / Q000000981:diagnostic imaging; D008875:Middle Aged; D011237:Predictive Value of Tests; D012680:Sensitivity and Specificity; D014055:Tomography, Emission-Computed / Q000379:methods
chemical_list: D005462:Fluorine Radioisotopes; D019788:Fluorodeoxyglucose F18; D003847:Deoxyglucose