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TITLE: Positron Emission Tomography (PET) for theEvaluation of Breast Lesions for Diagnosis of Breast CancerAUTHOR: Jeffrey A. Tice, MDAssistant Adjunct Professor of MedicineDivision of General Internal MedicineDepartment of MedicineUniversity of CA, San FranciscoPUBLISHER NAME: California Technology Assessment ForumDATE OF PUBLICATION: June 11, 2003PLACE OF PUBLICATION: San Francisco, CA
 
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POSITRON EMISSION TOMOGRAPHY FOR THE EVALUATIONOF BREAST LESIONS FOR DIAGNOSIS OF BREAST CANCERINTRODUCTION
The California Technology Assessment Forum is requested to review thescientific evidence for the use of Positron Emission Tomography (PET) for evaluating breast cancer in clinical practice. Specifically, we will review theevidence for the use of the glucose analog, 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) as a tracer in PET imaging for (1) the evaluation of breast lesionsfor diagnosis of breast cancer and (2) staging axillary lymph nodes. Subsequentreviews will focus on the detection of locoregional recurrence or distantmetastases/recurrence and the evaluation of response to chemotherapy.
BACKGROUND
 
Breast cancer
In 2002, there were an estimated 203,500 new cases of invasive breast cancer inthe United States and an estimated 40,000 deaths from this cancer. This representsapproximately 31% of all new cancer cases in women and 15% of all cancer deaths in women (2002;ACS 2002). In addition to invasive breast cancer, 54,300new cases of in situ breast cancer were estimated to be diagnosed in women in2002. Cancer of the breast is the most common form of cancer in women. Theaverage American woman is estimated to have a 1 in 8 chance of developing breast cancer at some time during her life.Most patients with breast cancer present with the complaint of a breast mass or anabnormal screening mammogram. A fine-needle aspiration, core needle biopsy, or open surgical biopsy can be used to obtain a definitive tissue diagnosis of breastcancer.Once breast cancer has been diagnosed, staging depends on assessment of boththe tumor size and regional lymph node involvement. A patient’s prognosis isdirectly related to the initial stage of her breast cancer. Prior to the initial surgicalmanagement of breast cancer and after making a tissue diagnosis of breast cancer,the patient undergoes a clinical staging evaluation.
 
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BACKGROUND,
continued
Breast cancer (continued)
This includes bilateral mammography (to evaluate for synchronous cancer), acomplete physical examination, chest radiography, and liver function tests.Further testing is done only if abnormalities are found during this evaluation.Based on this presurgical evaluation the patient is assigned a clinical stage for her  breast cancer using the TNM staging system (AJCC 1997) of the American JointCommittee on Cancer (Table 1). This classification describes tumor size (T), nodeinvolvement (N), and evidence of metastasis (M). Initial treatment options arethen determined using the presurgical tumor stage. Patients with early stageinvasive cancers (defined as stage I or II) usually undergo some form of localsurgical excision to completely remove the tumor.Table 1: TNM Staging for Breast Cancer Tumor: Tis Carcinoma in situT0 No evidence of primary tumor T1 Tumor 
≤
2 cmT2 Tumor >2 cm but
≤
5 cmT3 Tumor >5 cmT4 Tumor with direct extension to chest wall or skin Nodes: N0 No regional node metastases N1 Metastases to ipsilateral axillary nodes, mobile N2 Metastases to ipsilateral axillary nodes, fixed N3 Metastases to ipsilateral internal mammary nodesMetastases: M0 No distant metastasesM1 Metastases presentStage: 0 Tis, N0, M0I T1, N0, M0II A T0 or T1, N1, M0 or T2, N0, M0II B T2, N1, M0 or T3, N0, M0III A T0 or T1 or T2, N2, M0 or T3, N1 or N2, M0III B Any T, N3 M0 or T4, Any N, M0IV Any T, any N, M1
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