Rationale and Objectives
The aim of this study was to determine an optimum standardized uptake value (SUV) threshold for identifying regional nodal metastasis on 18 F–fluorodeoxyglucose (FDG) positron emission tomographic (PET)/computed tomographic (CT) studies of patients with inflammatory breast cancer.
Materials and Methods
A database search was performed of patients newly diagnosed with inflammatory breast cancer who underwent 18 F-FDG PET/CT imaging at the time of diagnosis at a single institution between January 1, 2001, and September 30, 2009. Three radiologists blinded to the histopathology of the regional lymph nodes retrospectively analyzed all 18 F-FDG PET/CT images by measuring the maximum SUV (SUVmax) in visually abnormal nodes. The accuracy of 18 F-FDG PET/CT image interpretation was correlated with histopathology when available. Receiver-operating characteristic curve analysis was performed to assess the diagnostic performance of PET/CT imaging. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using three different SUV cutoff values (2.0, 2.5, and 3.0).
Results
A total of 888 regional nodal basins, including bilateral axillary, infraclavicular, internal mammary, and supraclavicular lymph nodes, were evaluated in 111 patients (mean age, 56 years). Of the 888 nodal basins, 625 (70%) were negative and 263 (30%) were positive for metastasis. Malignant lymph nodes had significantly higher SUVmax than benign lymph nodes ( P < .0001). An SUVmax of 2.0 showed the highest overall sensitivity (89%) and specificity (99%) for the diagnosis of malignant disease.
Conclusions
SUVmax of regional lymph nodes on 18 F-FDG PET/CT imaging may help differentiate benign and malignant lymph nodes in patients with inflammatory breast cancer. An SUV cutoff of 2 provided the best accuracy in identifying regional nodal metastasis in this patient population.
Inflammatory breast cancer (IBC) is an aggressive disease that accounts for 1% to 5% of all breast cancers. It is a clinicopathologic entity characterized by changes in the breast such as erythema, edema involving more than two thirds of the breast, peau d’orange, enlargement, warmth, tenderness, and induration on palpation . In general, compared to women with noninflammatory breast cancer, women with IBC present at a younger age, are more likely to have metastatic disease at diagnosis, and have shorter overall survival . The mean 5-year overall survival rate of patients with IBC who have undergone current multidisciplinary therapy is between 20% and 40% .
The most significant prognostic factor for women with IBC is axillary lymph node involvement. Patients with axillary lymph node metastasis have shorter disease-free and overall survival than patients with node-negative disease . Accurate preoperative staging of patients with IBC is vital, because the standard of care for these patients is neoadjuvant therapy prior to mastectomy and surgical removal of the lymph nodes, after which histopathologic information about the number of involved axillary lymph nodes and the actual size of the primary tumor is no longer available.
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Materials and methods
Patients
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Imaging and Review
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Interpretation of 18 F-FDG PET/CT Findings
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Data Analysis
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Results
Clinical Data
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Table 1
Histopathologic Characteristics of Breast Cancer in 111 Patients with IBC
Characteristic_n_ % Histology IDC 50 45 IDC + DCIS 39 35 ILC 3 3 IMC 12 11 IMC + DCIS 7 6 Grade Missing 9 8 1 1 1 2 33 30 3 68 61 ER Missing 2 3 Negative 56 50 Positive 53 47 PR Missing 2 2 Negative 69 62 Positive 40 36 HER2/neu Missing 5 4 Negative 65 59 Positive 41 37
DCIS, ductal carcinoma in situ; ER, estrogen receptor; HER2/neu, human epidermal growth factor receptor 2; IBC, inflammatory breast cancer; IDC, invasive ductal cancer; ILC, invasive lobular cancer; IMC, invasive mammary cancer; PR, progesterone receptor.
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Table 2
Summary of Metastatic Status of 888 Regional Lymph Nodes by Location
Location Benign Malignant Axillary 107 115 Infraclavicular 154 68 Internal mammary 190 32 Supraclavicular 174 48 Total 625 263
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FDG Uptake in Regional Lymph Nodes
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Table 3
Summary of SUVs of 888 Benign and Malignant Lymph Nodes
Status_n_ SUV > 0 Total No Uptake SUV > 0 Mean ± Standard Deviation Minimum Median Maximum Benign 625 620 5 3.6 ± 1.91 1.2 4.3 5.9 Malignant 263 19 244 7.6 ± 5.79 1.2 5.8 42.3
SUV, standardized uptake value.
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Table 4
Size of 263 Malignant Lymph Nodes by Location
Malignant Lymph Nodes by Location_n_ Size (cm) Mean ± Standard Deviation Minimum Median Maximum Axillary 115 2.1 ± 0.86 0.8 1.9 5.7 Infraclavicular 68 1.1 ± 0.51 0.3 1 3.5 Internal mammary 32 1.1 ± 0.44 0.4 1 2.2 Supraclavicular 48 1.1 ± 0.48 0.3 1 2.3 All 263 1.5 ± 0.84 0.3 1.4 5.7
Table 5
SUVmax and Sizes of Five False-positive Lymph Nodes by Location
Location SUVmax Size (cm) Axillary 1.2 0.6 Axillary 5.9 1.7 Infraclavicular 4.3 0.6 Internal mammary 2.1 0.7 Supraclavicular 4.5 1.4
SUVmax, maximum standardized uptake value.
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Comparison of Different SUV Cutoff Points
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Table 6
Diagnostic Performance with Different SUV Thresholds on 888 Regional Lymph Nodes
SUV 2.0 2.5 3.0 True-positives 235 223 204 True-negatives 621 622 622 False-positives 4 3 3 False-negatives 28 40 59 Positive predictive value 98 99 99 Negative predictive value 96 94 91 Specificity 99 100 100 Sensitivity 89 85 78
SUV, standardized uptake value.
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Discussion
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Table 7
Sensitivity and Specificity Using Different SUV Thresholds
Location SUV 2.0 SUV 2.5 SUV 3.0 Sensitivity (%) Specificity (%) Sensitivity (%) Specificity (%) Sensitivity (%) Specificity (%) Axillary 94 99 90 99 87 99 Infraclavicular 87 99 82 99 72 99 Supraclavicular 79 99 77 99 65 99 Internal mammary 94 99 84 100 75 100
SUV, standardized uptake value.
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Conclusions
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