18F-fluorodeoxyglucose (FDG) PET is increasingly used in restaging advanced or recurrent breast cancer and in monitoring response to therapy and has received approval for Medicare re-imbursement for these clinical indications. CMS covers PET for breast cancer staging except axillary staging. It covers FDG PET as an adjunct to standard imaging modalities for staging patients with distant metastasis, restaging patients with locoregional recurrence or metastases and monitoring tumor response to treatment for locally advanced and metastatic breast cancer when a change in therapy is contemplated.
There are few reports in the literature comparing PET with conventional imaging methods for breast cancer staging or restaging. The guidelines that support its use are mostly for staging or an adjunct modality). NICE says: “Positron emission tomography fused with computed tomography (PET-CT) should only be used to make a new diagnosis of metastases for patients with breast cancer whose imaging is suspicious but not diagnostic of metastatic disease. NCCN does not specifically address PET for restaging(BINV-17). NCCN accepts PET for initial staging of patients with locally advanced or metastatic breast cancer when conventional staging studies (e.g., CT or bone scan) are equivocal or suspicious or for follow-up or surveillance patients with breast cancer when conventional studies (e.g., CT or bone scan) are equivocal or suspicious. This is a Category B recommendation/ A recent review (Rosen et al) says: “FDG PET and PET/CT have been shown to be particularly useful in the restaging of breast cancer, in evaluation of response to therapy, and as a problem-solving method when results of conventional imaging are equivocal. In these situations, FDG PET often demonstrates locoregional or unsuspected distant disease that affects management. PET has demonstrated a particular capability for evaluation of chemotherapy response in both patients with locally advanced breast carcinoma and those with metastatic disease.” Tateishi et al (2008) described how PET can be used to also monitor bone disease on therapy.
In summary, use of PET to restage on therapy is quite accepted and widespread and supported by a significant body of literature.
NCCN, Breast Cancer 2019
in S, Kim SB, Ahn JH, et al. 18 F-fluorodeoxyglucose uptake predicts pathological complete response after neoadjuvant chemotherapy for breast cancer: a retrospective cohort study. J SurgOncol. 2013;107(2):180-187.
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Tateishi U, Gamez C, Dawood S, Yeung HWD, Cristofanilli M, Macapinlac HA. Bone metastases in patients with metastatic breast cancer: morphologic and metabolic monitoring of response to systemic therapy with integrated PET/CT. Radiology 2008; 247(1): 189–196.