Research Article| Volume 43, ISSUE 4, P625-635, April 2017

Download started.


PET/CT with 18F-FDG predicts short-term outcome in stage II/III breast cancer patients upstaged to N2/3 nodal disease

Published:October 31, 2016DOI:



      18F-FDG PET/CT has high positive predictive value for the detection of avid lymph node metastases in breast cancer patients. We analysed the effect of upstaging lymph nodes by PET/CT on short-term outcome in stage II/III breast cancer patients.

      Patients and methods

      A total of 278 stage II/III primary breast cancer patients (mean age 48.9 years, range 19–75 years) were re-staged with 18F-FDG PET/CT before start of pre-operative systemic treatment (PST). Patients were divided in three groups based on risk for local recurrence: a low – (T2N0), intermediate – (T0-2N1 and T3N0) and a high-risk group (T0-3N2–3, T3N1 and T4). Within these groups we looked at local recurrence-free survival (LRFS), recurrence-free survival (RFS) and overall survival (OS) within the first 3 years of follow-up.


      With a median follow-up (FU) of 50 months the RFS, LRFS and OS were 87%, 88% and 92% respectively for the whole group. PET/CT upstaged 43 patients from the low- and intermediate risk group to the high-risk group, based on detection of ≥4 avid axillary nodes or occult N2/3-disease. Patients upstaged with PET/CT had more events for all three analyses compared to the original risk groups, which resulted in a significantly worse RFS (69.8%; p = 0.03) a nearly significantly worse LRFS (p = 0.052) and no effect in OS (p = 0.433).


      Additional PET/CT staging allows breast cancer patients to be treated according to the true stage, still stage II/III breast cancer patients upstaged to N2/3 by PET/CT have worse short-term outcome, despite adjustment of treatment, than patients staged high-risk with conventional imaging.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Surgical Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • van der Hage J.A.
        • van de Velde C.J.
        • Julien J.P.
        • Tubiana-Hulin M.
        • Vandervelden C.
        • Duchateau L.
        Preoperative chemotherapy in primary operable breast cancer: results from the European Organization for Research and Treatment of Cancer trial 10902.
        J Clin Oncol. 2001; 19: 4224-4237
        • von Minckwitz G.
        • Untch M.
        • Blohmer J.-U.
        • et al.
        Definition and impact of pathologic complete response on prognosis after neoadjuvant chemotherapy in various intrinsic breast cancer subtypes.
        J Clin Oncol. 2012; 30: 1796-1804
        • Groheux D.
        • Giacchetti S.
        • Delord M.
        • et al.
        18F-FDG PET/CT in staging patients with locally advanced or inflammatory breast cancer: comparison to conventional staging.
        J Nucl Med. 2013; 54: 5-11
        • Koolen B.B.
        • Vrancken Peeters M.-J.T.F.D.
        • Aukema T.S.
        • et al.
        18F-FDG PET/CT as a staging procedure in primary stage II and III breast cancer: comparison with conventional imaging techniques.
        Breast Cancer Res Treat. 2012; 131: 117-126
        • Segaert I.
        • Mottaghy F.
        • Ceyssens S.
        • et al.
        Additional value of PET-CT in staging of clinical stage IIB and III breast cancer.
        Breast J. 2010; 16: 617-624
        • Houssami N.
        • Ciatto S.
        • Turner R.M.
        • Cody H.S.
        • Macaskill P.
        Preoperative ultrasound-guided needle biopsy of axillary nodes in invasive breast cancer: meta-analysis of its accuracy and utility in staging the axilla.
        Ann Surg. 2011; 254: 243-251
        • Diepstraten S.C.E.
        • Sever A.R.
        • Buckens C.F.M.
        • et al.
        Value of preoperative ultrasound-guided axillary lymph node biopsy for preventing completion axillary lymph node dissection in breast cancer: a systematic review and meta-analysis.
        Ann Surg Oncol. 2014; 21: 51-59
        • Veronesi U.
        • Paganelli G.
        • Viale G.
        • et al.
        A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer.
        N Engl J Med. 2003; 349: 546-553
        • Bernsdorf M.
        • Berthelsen A.K.
        • Wielenga V.T.
        • et al.
        Preoperative PET/CT in early-stage breast cancer.
        Ann Oncol. 2012; 23: 2277-2282
        • Koolen B.B.
        • Valdés Olmos R.A.
        • Elkhuizen P.H.M.
        • et al.
        Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy.
        Breast Cancer Res Treat. 2012; 135: 231-240
        • Goldhirsch A.
        • Ingle J.N.
        • Gelber R.D.
        • Coates A.S.
        • Thürlimann B.
        • Senn H.-J.
        Thresholds for therapies: highlights of the St Gallen International Expert Consensus on the primary therapy of early breast cancer 2009.
        Ann Oncol. 2009; 20: 1319-1329
        • Whelan T.J.
        • Olivotto I.A.
        • Parulekar W.R.
        • et al.
        Regional nodal irradiation in early-stage breast cancer.
        N Engl J Med. 2015; 373: 307-316
        • Poortmans P.M.
        • Collette S.
        • Kirkove C.
        • et al.
        Internal mammary and medial supraclavicular irradiation in breast cancer.
        N Engl J Med. 2015; 373: 317-327
        • Koolen B.B.
        • Valdés Olmos R.A.
        • Vogel W.V.
        • et al.
        Pre-chemotherapy 18F-FDG PET/CT upstages nodal stage in stage II-III breast cancer patients treated with neoadjuvant chemotherapy.
        Breast Cancer Res Treat. 2013; 141: 249-254
        • Straver M.E.
        • Loo C.E.
        • Alderliesten T.
        • Rutgers E.J.T.
        • Vrancken Peeters M.T.F.D.
        Marking the axilla with radioactive iodine seeds (MARI procedure) may reduce the need for axillary dissection after neoadjuvant chemotherapy for breast cancer.
        Br J Surg. 2010; 97: 1226-1231
        • Aukema T.S.
        • Vogel W.V.
        • Hoefnagel C.A.
        • Valdés Olmos R.A.
        Prevention of brown adipose tissue activation in 18F-FDG PET/CT of breast cancer patients receiving neoadjuvant systemic therapy.
        J Nucl Med Technol. 2010; 38: 24-27
        • Poortmans P.
        Irradiation of the internal mammary and medial supraclavicular lymph nodes in stage I to III breast cancer: 10 years results of the EORTC Radiation Oncology and Breast Cancer Groups phase III trial 22922/10925.
        Eur J Cancer. 2013; 47
        • McGale P.
        • Taylor C.
        • Correa C.
        • et al.
        Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials.
        Lancet. 2014; 383: 2127-2135
        • Overgaard M.
        • Nielsen H.M.
        • Overgaard J.
        Is the benefit of postmastectomy irradiation limited to patients with four or more positive nodes, as recommended in international consensus reports? A subgroup analysis of the DBCG 82 b&c randomized trials.
        Radiother Oncol. 2007; 82: 247-253
        • Burstein H.J.
        • Morrow M.
        Nodal irradiation after breast-cancer surgery in the era of effective adjuvant therapy.
        N Engl J Med. 2015; 373: 1-3
        • Donker M.
        • van Tienhoven G.
        • Straver M.E.
        • et al.
        Radiotherapy or surgery of the axilla after a positive sentinel node in breast cancer (EORTC 10981-22023 AMAROS):a randomised, multicentre, open-label, phase 3 non-inferiority trial Mila.
        Lancet Oncol. 2014; 15: 1303-1310
        • Courdi A.
        • Chamorey E.
        • Ferrero J.-M.
        • Hannoun-Lévi J.-M.
        Influence of internal mammary node irradiation on long-term outcome and contralateral breast cancer incidence in node-negative breast cancer patients.
        Radiother Oncol. 2013; 108: 259-265
        • Straver M.E.
        • Aukema T.S.
        • Olmos R.A.V.
        • et al.
        Feasibility of FDG PET/CT to monitor the response of axillary lymph node metastases to neoadjuvant chemotherapy in breast cancer patients.
        Eur J Nucl Med Mol Imaging. 2010; 37: 1069-1076
        • Peare R.
        • Staff R.T.
        • Heys S.D.
        The use of FDG-PET in assessing axillary lymph node status in breast cancer: a systematic review and meta-analysis of the literature.
        Breast Cancer Res Treat. 2010; 123: 281-290
        • Kuehn T.
        • Bauerfeind I.
        • Fehm T.
        • et al.
        Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study.
        Lancet Oncol. 2013; 14: 609-618
        • Boughey J.C.
        • Suman V.J.
        • Mittendorf E.A.
        • et al.
        Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial.
        JAMA. 2013; 310: 1455-1461