Breast Case Study qxd by mikesanye


									                                                                                                                 Case Study

                                                                             Restaging & Therapy Monitoring

55-year-old female,                    Clinical Question                                  Clinical Question
referred by a medical oncologist.
                                       The presence of distant                            Conventional imaging demon-
Diagnosis                              metastatic disease would alter                     strates no change in anatomic
• Diagnosed 5 years prior with         the course of treatment for this                   structure. Has there been a
  bilateral breast cancer: left T1N0   patient, and the CT and MR                         change in the metabolism of the
  and right T1N0. Poorly differenti-
  ated ductal carcinoma, with          results are inconclusive. What                     previously identified lesions?
  micrometastases in 3 out of 22       is the full extent of disease?
  axillary lymph nodes on the right,                                                      Follow-up PET Restaging
  was confirmed with biopsy.           PET Restaging                                      PET reveals progressive
                                       Confirms metastatic disease.                       metastatic disease.
                                       • Wholebody PET demonstrated                       • PET revealed progressive, wide-
• Patient underwent bilateral
                                         multiple, metabolically-active                     spread metastatic disease with
                                         metastases in the bihilar region                   left supraclavicular, mediastinal
• Surgery was followed with 4            and lower mediastinum not evident                  and bihilar lymphadenopathy
  rounds of Adriamycin and Cytoxin       with CT or MR (Fig. 1, June ’01).                  (not shown).
  chemotherapy and then ongoing
                                       • No hepatic lesions and no bone                   • At least one hepatic metastasis.
                                         lesions were observed (Fig. 2,                     Multiple skeletal metastases.
                                         June ’01).
Anatomic Restaging
                                                                                          Treatment Change
• 3 years post diagnosis, patient      Treatment Change                                   • Patient’s chemotherapy was
  presented with rising CEA.
                                       • Patient underwent 4 months of                      changed to Navelbine, including
• CT of the chest, thoracic spine,       chemotherapy with Femara, resulting                Anzemet, Herceptin, Heparin
  lumbar spine and pelvis showed an      in slightly decreased tumor markers.               and Zometa.
  enhancing liver lesion which was
                                                                                          • After 6 months, tumor markers
  biopsied negative/inconclusively.    Follow-up Anatomic                                   were still elevating slightly.
• MR of the abdomen demonstrated
  enhancing superior hepatic mass      • Repeat CT of the abdomen and
  suggestive of a metastatic lesion.     pelvis, and bone scan, indicated no
                                         change in status from previous scans.

                                       Fig. 1 – PET demonstrates improvement in left supraclavicular,
                                       mediastinal and bihilar lymphadenopathy.

                                            June 2001               June 2001               October 2002

                                                                                        Case study courtesy of Morton Plant Hospital.
                                          Fig. 2 – PET demonstrates advancing hepatic metastatic disease.
Clinical Question
How can we explain the
continuously elevating markers?

Second Follow-up PET Restaging
PET reveals interval progression
of metastatic disease.
• PET demonstrated an increase in
  the number of metabolically-active
  lesions in the hepatic parenchyma
  (Fig. 2, Oct.’02).
                                               June 2001             October 2002              October 2002
• Some interval improvement in the
  bihilar region suggesting improving
  mets or diminished inflammatory
  changes (Fig 1, Oct. ’02).              Positron Emission Tomography (PET) Overview
• Bone lesions appear stable or slow      PET is a non-invasive diagnostic imaging procedure that can provide unique
  progressive, with suspicious new        information for accurate TNM staging. Many cancers exhibit increased glucose
  lesion in the right anterior iliac      metabolic rates which can be identified with PET. Since changes in glucose
  crest, right trochanteric region and
  possibly the lower lumbar spine.        metabolism often occur before changes in anatomy (e.g., tumor growth),
                                          PET can often identify the presence of disease earlier than other anatomic
Patient Outcome                           imaging techniques. Early disease identification is particularly critical during
• Treatment was changed again, to         the assessment of nodal involvement or the determination of the presence
  Gemzar, and patient is still being      of metastatic disease.
• Patient exhibits stable to decreasing
  tumor markers.
                                                                                             PET         PET
                                                                                           Sensitivity Specificity
PET Restaging Protocol
Wholebody PET scan.                         Axillary node staging 1                          94%         86%
10 mCi of FDG were administered
60 minutes prior to scan.                   Detection of recurrent
                                            or metastatic disease 2                              94%                  80%
                                            Prediction of complete
                                            remission following a
                                            single source of therapy 3                           90%                  74%
                                            1 Greco M, J Natl Cancer Inst 2001; 93: 630.
                                            2 Kim TS, World J Surg. 2001; 25: 829.
                                            3 Smith IC, J Clin Oncol 2000; 18: 1676.


                                                                                                                 PET 048 10K 09-02

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