Lay Summary: More extensive staging that is recommended by guidelines is commonly performed for stage II breast cancer but it can be avoided.

Stage II is divided into stage IIA and stage IIB based on tumor size and whether it has spread to the axillary lymph nodes (the lymph nodes under the arm). In stage IIA, the cancer is either not larger than 2 centimeters and has spread to the axillary lymph nodes, or between 2 and 5 centimeters but has not spread to the axillary lymph nodes. In stage IIB, the cancer is either between 2 and 5 centimeters and has spread to the axillary lymph nodes, or larger than 5 centimeters but has not spread to the axillary lymph nodes. This is a situation in which common practice is against literature and guideline statements. It is common for this stage to be evaluated with CT scans to rule out distant metastastes but the literature indicates that the risk of mets is so small that such staging is not indicated. In women who have pathological stage II tumours, a postoperative bone scan is recommended as part of baseline staging. Routine liver ultrasonography and chest radiography are not indicated in this group but could be considered for patients with 4 or more positive lymph nodes. Abdominal and pelvic CT is only NCCN recommended if there are specific test elevations or pulmonary symptoms.

The yield of positive results among these patients was 2% with bone scanning, and less than 1% with ultrasonography and with chest radiography. A good case could be made for retaining bone scanning and eliminating the other 2 tests in this patient group. The possibility of dividing the stage II group according to size of tumor or number of positive lymph nodes (fewer than 4 v. 4 or more) was considered in one guideline based on the assumption that risk might vary across the range of stage II disease. For example, a larger number of positive nodes could be associated with a higher likelihood of detecting metastases with the staging tests. However, data were not available to answer this question. Nonetheless, the guideline group felt it appropriate to consider the addition of liver ultrasonography and chest radiography in women with 4 or more positive lymph nodes.

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David A. Mankoff and Jennifer M. Specht, University of Washington; Seattle Cancer Care Alliance, Seattle, WA William B. Eubank, University of Washington; Puget Sound Veterans Affairs Medical Center, Seattle, WA Larry Kessler, University of Washington, Seattle, WA [18F]Fluorodeoxyglucose Positron Emission Tomography–Computed Tomography in Breast Cancer: When… and When Not? JCO April 20, 2012 vol. 30 no. 12 1252-1254