J Korean Soc Radiol.  2014 Feb;70(2):145-152. 10.3348/jksr.2014.70.2.145.

Utility of Second-Look Examinations in the Management of a New Hypermetabolic Lesion Detected by Fluorodeoxyglucose Positron Emission Tomography/CT for Diagnosis of Loco-Regional Recurrence in Patients with Breast Cancer

• Park J
• Cho KR
• Park EK
• Seo BK
• Woo OH
• Song SE
• Oh YW
• Bae JW

• KMID: 1839424
• DOI: http://doi.org/10.3348/jksr.2014.70.2.145

Abstract

PURPOSE
To investigate the clinical significance of a new hypermetabolic lesion detected by fluorodeoxyglucose positron emission tomography/CT (FDG-PET/CT) as well as the utility of second-look examinations to evaluate loco-regional recurrence of breast cancer.
MATERIALS AND METHODS
Our database revealed 922 breast cancer patients who underwent surgery from January 2008 to July 2011. We included 20 patients with negative findings on routine follow-up but with new hypermetabolic lesions on FDG-PET/CT. All underwent second-look examination [breast ultrasound (US) = 14, chest CT scan = 6]. A total of 17 cases were pathologically verified and 3 were diagnosed with follow-up imaging.
RESULTS
The locations were in the axillae (n = 7), breast (n = 6), chest wall (n = 3), cervical/supraclavicular (n = 3), and internal mammary (n = 1). Of the 20 hypermetabolic lesions, 10 were pathologically confirmed malignancies. Of the 14 patients who had undergone US, 7 had suspicious findings and 5 were confirmed as malignancies. Of a total of 6 patients who had undergone CT scans, 5 had suspicious findings and all turned out to be malignancies. The positive predictive value of the second-look examination was 83.3% (10/12).
CONCLUSION
Second-look examination and pathologic confirmation should be performed for newly appearing hypermetabolic lesions on FDG-PET/CT in order to exclude loco-regional recurrence in breast cancer patients.

MeSH Terms

Axilla
Breast Neoplasms*
Breast*
Diagnosis*
Electrons*
Follow-Up Studies
Humans
Recurrence*
Thoracic Wall
Tomography, X-Ray Computed
Ultrasonography

Figure

• 

  Fig. 1 A 30-year-old woman who had undergone left modified radical mastectomy for mucinous carcinoma presented with a lesion suspicious for malignancy on a 3-year follow-up fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scan and confirmed as local recurrences on pathologic examination. A. FDG-PET/CT scan shows multifocal hypermetabolic nodular lesions in left axilla, pectoralis muscle, shoulder, and brachialis muscle (arrows). B. Second-look ultrasound shows multiple partially indistinct isoechoic masses (arrow) at the corresponding areas and these are considered to be BI-RADS category 5.

• 

  Fig. 2 A 54-year-old woman who had undergone left modified radical mastectomy presented with a lesion suspicious for malignancy on a 4.5-year follow-up fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scan but confirmed as benign reactive hyperplasia on pathologic specimen. A. FDG-PET/CT scan shows a newly developed hypermetabolic lesion in the right axilla (arrow) which is suspicious for metastatic lymphadenopathy. B. Second-look ultrasound shows a hypoechoic lymph node (arrow) in the right axilla. It shows eccentric cortical thickening, and so is considered to be a malignant lymph node (BI-RADS category 4a).

• 

  Fig. 3 A 67-year-old woman who underwent left modified radical mastectomy presented with a lesion concerning for malignancy on a 3 year 2 months follow-up fluorodeoxyglucose positron emission tomography (FDG-PET)/CT scan and confirmed to be a malignant lymph node on final pathologic examination. A. FDG-PET/CT scan shows a focal hypermetabolic nodule (arrow) in the left internal mammary area. B. Second-look chest CT scan shows a 0.5-cm enhancing nodular lesion (arrow) in the left internal mammary area. This is very small but not seen on previous imaging so considered to be a malignant lesion (BI-RADS category 4c).

• 

  Fig. 4 Hypermetabolic lesions detected by fluorodeoxyglucose positron emission tomography/CT correlated with second-look imaging and pathologic findings. The overall sensitivity, specificity, positive predictive values, and negative predictive values of second-look examination are 100% (10/10), 80% (8/10), 83.3% (10/12), and 100% (8/8).

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