Prepared by Karen Mourtzikos, MD from The Johns Hopkins
Hospital, Baltimore, MD and Javier Villanueva-Meyer, MD from
River Oaks Imaging, Houston, TX.
A 30-year-old woman was diagnosed with infiltrating ductal
carcinoma in the right breast in 1996. Since she had a family
history of breast cancer, she opted for bilateral mastectomy at the
time of her initial diagnosis, followed by recon-struction with
silicone implants. She subsequently underwent two cycles of
chemotherapy and radiation therapy. She was asymptomatic for 4
years, at which time she noticed erythema and swelling of the right
A right upper chest skin punch biopsy was performed in December
2000, and the pathology results showed carcinoma with features
favoring metastatic adenocarcinoma of the dermis.
Recurrent breast cancer in a patient with bilateral breast
In January 2001, 8 days after the biopsy, follow-up imaging was
performed. Radiologic workup with mammography, breast ultrasound,
and computed tomography (CT) of the chest, abdomen, and pelvis
showed clips and surgical changes in the right axilla, with no
evidence of local recurrence or lymph node involvement.
Positron emission tomography (PET) done with 10 mCi
fluorodeoxyglucose (FDG) and dedicated-ring bismuth germanate (BGO)
system showed abnormal increased uptake in the superior-posterior
aspect of the right implant, in the right supraclavicular region,
and in the left axilla (Figure 1).
The PET results helped determine the extent of the patient's
surgery, which included removal of both implants, as well as left
axillary and right supraclavicular dissection.
A follow-up PET done 3 months postoperatively was normal (Figure
2). At 6 months after surgery, she had no clinical evidence of
The role of PET in this patient was integral to the course of
her care. Conventional imaging (including mammography, ultrasound,
and CT) had been unable to identify the recurrence adjacent to the
right breast implant, or the spread to the supraclavicular and
bilateral axillary lymph nodes. Breast MR was not performed in this
patient. Studies comparing the use of ultrasound, mammography, and
FDG PET in the detection of breast cancer in patients with breast
augmentation have demonstrated FDG PET was able to identify
suspicious lesions as cancerous.
There was, however, limited information in the literature
examining the efficacy of standard radiological modalities
(mammography, ultrasound, CT and MR) in evaluating breast cancer
spread and recurrence in patients who underwent reconstructive
mammoplasy following mastectomy for breast cancer. Azavedo and Boné
concluded that MR was the leading technique in imaging silicone
breast implants and stated that it would be most suitable for
assessing post-reconstruction recurrence when compared with
mammography, ultrasound, and CT. Breast MR had emerged initially as
an answer to uncertainties presented by the limited mammography and
ultrasound studies in the setting of breast implants. Piccoli et al
stated, however, that MR itself was subject to limitations
presented by imaging parameters and contrast agent delivery as well
as the menstrual status of the patient and the vascularity of the
lesion. These factors adversely affect the ability of MRI to
distinguish cancerous lesions in the setting of breast
Furthermore, MR is unable to distinguish benign processes, such
as peri-implant inflammation or fibrosis, from malignant ones.
Although FDG PET cannot be utilized as a screening tool for
asymptomatic patients due to its limited resolution for small
tumors, it is very effective as a staging tool.
Furthermore, it is not affected adversely by breast tissue density,
breast surgery, breast augmentation, breast implants, or dysplastic
tissue, which can cause false-positive findings on MR.
The application of PET, was highly effective in this case, after
the traditional modalities had been unable to identify the
recurrence and metastatic spread in the setting of bilateral
mastectomy and implant reconstruction.
FDG PET guided the extent of surgery and was utilized for
follow-up surveillance. At 3 months postoperative, the patient was
tumor free, as demonstrated by PET, and remains without clinical
evidence of recurrence 6 months after surgery. The comparison of
existing modalities and PET for follow-up and restaging in patients
who have had breast reconstruction with implants after mastectomy
for breast cancer bears further study to define more clearly the
most suitable method for evaluation, as well as the role of FDG PET
in the management of this subgroup of women.
As of October 1, 2002, Medicare will start reimbursing for PET
scans for breast cancer staging, restaging, and monitoring of
response to therapy. This application, such as shown in this case,
will become routine clinical practice and will allow for the early
detection of recurrent breast cancer in women with implants.