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with a higher SUV had a significantly poorer prognosis than those patients with lower values.

The skeleton is the most common site of distant metastases in breast cancer. Bone scintigraphy is considered the most sensitive method for detecting and determining the extent of skeletal metastases. However, purely lytic lesions or metastases confined to the marrow cavity may be difficult to detect on a bone scan, due to the lack of a sufficient osteoblastic response.199 Cook et al.200 reported that the level of FDG uptake in lytic lesions was significantly greater compared with osteoblastic lesions and that the prognosis of patients with predominantly lytic disease was significantly worse.

Osseous metastases are a frequent finding in breast cancer; approximately 70% of patients with advanced disease have an osseous metastasis, which is a major contributor to morbidity and treatment cost.201 The median survival for these patients is 24 months and the 5-year survival is 20%. Breast cancer causes osteolytic more often than osteoblas-tic metastatic lesions, although osteoblastic changes often develop after treatment.

The reported higher sensitivity of FDG-PET for detection of osteolytic lesions likely reflects the ability of FDG-PET to detect metastatic deposits in the bone marrow before the development of a significant reactive bone formation that is necessary for detection by bone scintigraphy. FDG-PET detection of osseous metastatic disease appears to be unrelated to reactive bone formation, but rather is related to detection of the metabolic activity of the tumor cells.

18F-Fluoride PET may provide improved detection of bone metastases in breast cancer, and in other tumors, because its concentration is approximately twofold greater than that of 99mTc-methylene disphosphonate (99mTc-MDP) and its clearance is faster, resulting in a higher bone to background ratio. Schirrmeister et al.202 compared a whole-body 18F-PET scan with a whole body 99mTc-MDP scan and demonstrated that the former detected more lesions in more patients than the conventional bone scan. Finally, it was found that FDG-PET changed the clinical stage in 36% of patients with breast cancer and the management in 58%.203

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