Erken evre meme kanserli hastalarda PET/BT nin rolünün değerlendirilmesi
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Date
2010
Authors
Aydın, Nesrin
Journal Title
Journal ISSN
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Publisher
Uludağ Üniversitesi
Abstract
Meme kanseri batı toplumlarında kadınlarda en çok görülen ve akciğer kanserinden sonra ikinci sıklıkta ölüme neden olan kanser türüdür. Meme kanserinde tedavi öncesi evrelemeyi doğru yapmak, pronozu ve tedavi seçeneklerini belirlemek açısından büyük önem taşımaktadır. Mamografi semptomatik ve asemptomatik olgularda primer lezyonun tanısında en çok kullanılan yöntemdir. Okült meme tümörlerinin saptanmasında Ultrason (US) ve manyetik rezonans (MRI), mamografi bulgularıyla korele edilerek ayırıcı tanıya yardımcı olur. Evrelemede primer tümör ile birlikte bölgesel lenf nodu metastazı ve uzak metastaz saptanmasında bu modalitelerin yanı sıra sentinel lenf nodu biyopsisi (SLNB), toraks radyografisi, aksiller ve abdominal US, kemik sintigrafisi rutinde kullanılan yöntemlerdir. Tanısal yöntemlerin bazı eksiklik, kusur ve yan etkileri mevcuttur. SLNB invaziv girişimi gerektirmesiyle birtakım komplikasyonlar içermektedir. Mamografide yağ nekrozu, skar ve fibrokistik değişiklikler tümör dokusuyla benzer bulgular verebilir. Ayrıca yoğun dokulu, cerrahi ve radyoterapi uygulanmış olgularda mamografinin özgüllüğü düşmektedir. Hem morfolojik hem fonksiyonel bilgiler sunan, non invaziv tüm vücut görüntüleme avantajı ile F-18 ile işaretli fluorodeoksiglukoz (FDG) ile gerçekleştirilen ve bilgisayarlı tomografi entegre edilmiş Pozitron Emisyon Tomografisi (PET/BT), meme kanserinde diğer görüntüleme yöntemlerinin sınırlılıklarını aşabilen, zaman kaybı ve maliyeti düşürebilecek bir teknik olarak bilinmektedir. Bununla birlikte küçük boyutlu tümörlerde tekniğin yanlış negatifliği olduğunu gösteren çalışmalar mevcuttur. Bu çalışmada bölümümüzde Haziran 2006-Aralık 2009 tarihleri arasında erken evre (T1-2) meme kanseri tanısıyla preoperatif evreleme amaçlı PET/BT çekimi yapılan 35 olgu retrospektif olarak değerlendirildi. PET/BT bulguları, gerçekleştirilen invaziv girişimler sonrası elde edilen histopatolojik bulgular ve alınan klinik kararlarla karşılaştırılarak PET/BT'nin erken meme tümörlerinde (T1,T2) evrelemedeki etkinliği araştırıldı. İnce iğne aspirasyon biyopsisi ve tru-cut biyopsi ile tanı konulmuş olan 31/35 (%88) olguda FDG PET/BT'nin tümör tanısında duyarlılığı %90, pozitif öngörü değeri %100 ve doğruluğu %90 bulundu. PET/BT ile primer tümörün saptanamadığı diğer 3 olguda tümör boyutları 1 cm'den küçüktü. Memedeki tümörde steroid reseptör durumu ve SUVmax değerleri arasında anlamlı korelasyon saptanmazken, tümör boyutu 2-5 cm arasında olan olgularda SUVmax değerinin boyutla pozitif korelasyon gösterdiği görüldü.PET/BT sonrası cerrahi tedavi uygulanan 19 (%54) olguda ve aksiller lenf nodu biyopsisi yapılan 9 (%25) olguda aksiller lenf nodu metastazını göstermede PET/BT'nin duyarlılığı %84.61, özgüllüğü %73.33, pozitif öngörü değeri %73.33, negatif öngörü değeri %84.61 ve doğruluğu % 78.57 bulundu. 8/35 olguda (%22) N3 lenf nodu saptandı. Bu olgulardan iki tanesinde ipsilateral internal mammarian lenf nodu metastazı saptandı. 5/35 olguda (%14) PET/BT'de uzak metastaz tespit edildi. Bunlardan 3 tanesinde kemik metastazı 2 tanesinde akciğer metastazı mevcuttu.Bu çalışmadan elde edilen veriler, Flor-18 FDG PET/BT'nin, erken evre meme kanserinin primer evrelemesinde etkin bir tanı metodunu ortaya koymaktadır. Bununla birlikte, lenf nodu metastazlarının ve 1 cm'den küçük meme lezyonlarının tanısında negatif öngörü değeri kabul edilebilir düzeyde olmadığından SLNB ve konvansiyonel tanı yöntemlerinin tam olarak yerini alabileceği söylenemez. Buna karşın N3 lenf nodu ve uzak metastaz saptama değeri konvansiyonel yöntemlere göre daha üstün görünmektedir. Bu nedenle sadece ileri evre olduğu değerlendirilen vakalar değil, erken evre meme kanserlerinde de tedavi öncesi evreleme sürecine PET/BT'nin dahil edilmesi evre değişikliğine yol açarak veya SLNB'yi gereksiz kılarak hasta yönetimine ciddi katkıda bulunabilir.
Breast cancer is the most frequently encountered and the second lethal cancer following lung in women from western countries. Accurate staging before therapy is crucial for estimating prognosis and therapy management in breast cancer.Mammography is the most frequently used diagnostic tool for primary lesion diagnosis in either symptomatic or asymptomatic patients. Ultrasound (US) and magnetic resonance (MRI) imaging assist to differential diagnosis of occult breast tumors by correlating with mammographic findings. As well as these modalities, sentinel lymph node biopsy (SLNB), thorax radiography, axillar and abdominal US and bone scintigraphy are used for primary tumor staging, together with regional lymph node metastasis and distant organ metastasis detection. These diagnostic methods have some lacks, faults and contraindications. SLNB has some complications because of the need for invasive operation. Adipose tissue necrosis, scar and fibrous changes may interfere with tumor tissue in mammography. Besides, the specificity of mammography is lower in dense, operated or radiotherapy applied breast tissues. Positron emission tomography integrated with computerized tomography (PET/CT) performed with F-18 labeled fluorodeoxyglucose (FDG) is known to be the method that not only surpasses the limitations of other diagnostic tools, but also reduces time and costs by providing both morphological and functional data and giving the advantage of noninvasive whole-body imaging. However, there are some papers that indicate false-negative results of this technique in small-sized tumors.In this study, 35 early stage (T1 and T2) breast cancer patients who underwent PET/CT for preoperative staging at our center between June 2006 and December 2009 were retrospectively evaluated. The efficiency of PET/CT in early stage (T1 and T2) breast tumors was investigated by comparing PET/CT findings with histopathological findings acquired from invasive procedures and final clinical decisions. In 31/35 (88%) patients who were diagnosed by fine needle aspiration biopsy or tru-cut biopsy, PET/CT sensitivity, positive predictive value and accuracy in tumor diagnosis were 90%, 100% and 90%, respectively. Three patients whose primary tumor cites could not be identified by PET/CT had tumor size less than 1 cm. There was no significant correlation with steroid receptor status of breast tumor and SUVmax values, however SUVmax values showed positive correlation with tumor size in patients with 2 to 5 cm sized tumors.In 19 (59%) patients that underwent surgery and 9 (25%) patients that underwent axillar lymph node biopsy following PET/CT scan, PET/CT sensitivity, specificity, positive predictive value and negative predictive value were 84.61%, 73.33%, 73.33% and 84.61%, respectively.N3 lymph node metastasis was detected in 8 (22%) patients. Ipsilateral internal mammarian lymph node metastasis was also detected in two of these patients. In 5 (14%) patients, distant metastasis was found by PET/CT. Three of these patients had bone metastasis and two of them had lung metastasis.The data acquired in this study show that fluor-18 FDG PET/CT is an effective diagnostic tool in the primary staging of early stage breast cancer. However, because of its not acceptable negative predictive value in lymph node metastases and breast lesions smaller than 1 cm, it can?t be claimed that PET/CT can supersede SLNB or conventional diagnostic methods. Nevertheless, the diagnostic value in N3 lymph node and distant metastasis detection seem to be superior to other conventional methods. Therefore, adding PET/CT to pretherapy staging procedure for patients not only in advanced stage, but also in early stage breast cancer, may provide significant benefit in therapy management by stage alteration and reducing the need for SLNB.
Breast cancer is the most frequently encountered and the second lethal cancer following lung in women from western countries. Accurate staging before therapy is crucial for estimating prognosis and therapy management in breast cancer.Mammography is the most frequently used diagnostic tool for primary lesion diagnosis in either symptomatic or asymptomatic patients. Ultrasound (US) and magnetic resonance (MRI) imaging assist to differential diagnosis of occult breast tumors by correlating with mammographic findings. As well as these modalities, sentinel lymph node biopsy (SLNB), thorax radiography, axillar and abdominal US and bone scintigraphy are used for primary tumor staging, together with regional lymph node metastasis and distant organ metastasis detection. These diagnostic methods have some lacks, faults and contraindications. SLNB has some complications because of the need for invasive operation. Adipose tissue necrosis, scar and fibrous changes may interfere with tumor tissue in mammography. Besides, the specificity of mammography is lower in dense, operated or radiotherapy applied breast tissues. Positron emission tomography integrated with computerized tomography (PET/CT) performed with F-18 labeled fluorodeoxyglucose (FDG) is known to be the method that not only surpasses the limitations of other diagnostic tools, but also reduces time and costs by providing both morphological and functional data and giving the advantage of noninvasive whole-body imaging. However, there are some papers that indicate false-negative results of this technique in small-sized tumors.In this study, 35 early stage (T1 and T2) breast cancer patients who underwent PET/CT for preoperative staging at our center between June 2006 and December 2009 were retrospectively evaluated. The efficiency of PET/CT in early stage (T1 and T2) breast tumors was investigated by comparing PET/CT findings with histopathological findings acquired from invasive procedures and final clinical decisions. In 31/35 (88%) patients who were diagnosed by fine needle aspiration biopsy or tru-cut biopsy, PET/CT sensitivity, positive predictive value and accuracy in tumor diagnosis were 90%, 100% and 90%, respectively. Three patients whose primary tumor cites could not be identified by PET/CT had tumor size less than 1 cm. There was no significant correlation with steroid receptor status of breast tumor and SUVmax values, however SUVmax values showed positive correlation with tumor size in patients with 2 to 5 cm sized tumors.In 19 (59%) patients that underwent surgery and 9 (25%) patients that underwent axillar lymph node biopsy following PET/CT scan, PET/CT sensitivity, specificity, positive predictive value and negative predictive value were 84.61%, 73.33%, 73.33% and 84.61%, respectively.N3 lymph node metastasis was detected in 8 (22%) patients. Ipsilateral internal mammarian lymph node metastasis was also detected in two of these patients. In 5 (14%) patients, distant metastasis was found by PET/CT. Three of these patients had bone metastasis and two of them had lung metastasis.The data acquired in this study show that fluor-18 FDG PET/CT is an effective diagnostic tool in the primary staging of early stage breast cancer. However, because of its not acceptable negative predictive value in lymph node metastases and breast lesions smaller than 1 cm, it can?t be claimed that PET/CT can supersede SLNB or conventional diagnostic methods. Nevertheless, the diagnostic value in N3 lymph node and distant metastasis detection seem to be superior to other conventional methods. Therefore, adding PET/CT to pretherapy staging procedure for patients not only in advanced stage, but also in early stage breast cancer, may provide significant benefit in therapy management by stage alteration and reducing the need for SLNB.
Description
Keywords
Erken meme kanseri, FDG PET/BT, Evreleme, Early stage breast cancer, FDG PET/CT, Staging
Citation
Aydın, N. (2010). Erken evre meme kanserli hastalarda PET/BT nin rolünün değerlendirilmesi. Yayınlanmamış uzmanlık tezi. Uludağ Üniversitesi Tıp Fakültesi.