Do we need both bone scan and CT CAP in staging of newly diagnosed node positive breast cancer?

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1 Do we need both bone scan and CT CAP in staging of newly diagnosed node positive breast cancer? Poster No.: C-0797 Congress: ECR 2015 Type: Authors: Keywords: DOI: Scientific Exhibit F. L. McCloskey 1, M. Reilly 2, K. Reilly 2 ; 1 Belfast, County Antrim/ UK, 2 Derry/UK Cancer, Staging, Nuclear medicine conventional, CT, Lymph nodes, Breast, Bones /ecr2015/C-0797 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 9

2 Aims and objectives irefer guidelines state that in newly diagnosed breast cancer patients, staging for metastases is reserved for those with high pre-test probability or those who have symptoms suggestive of distal spread (1). The guidelines mention a range of potential investigations including ultrasound, x-ray, CT and nuclear medicine studies and state that the use of these should be guided by the local MDT (1). In our department in Altnagelvin Hospital, Northern Ireland, local guidelines dictate which newly diagnosed breast cancer patients undergo further imaging following initial diagnostic mammogram, ultrasound or MRI. If 4 or more axillary lymph nodes are patholgically proven to be involved in the disease process, further staging with both CT Chest, Abdomen and Pelvis and Nuclear Medicine Bone Scan is routinely performed. This patient subgroup is felt to have the highest pre-test probability of distant metastasis at time of diagnosis and, therefore, routinely undergo these two investigations. We saught to determine if both investigations were justified in determining the presence or absence of bone metastases or if CT Chest, Abdomen and Pelvis alone would suffice. We were primarily driven by the IRMER principles, including the professional and legal duty to keep radiation exposure as low as reasonable possible. Of course, we also wanted to save the patient additional trips to the hospital at an inevitably upsetting time. Additionally, in the current economic climate, we should also be aware of the cost of studies. Consultation with the multi-disciplinerary team when considering if additional studies will actually alter management plan is key. To apply this thought process to our study, if the CT scan demonstrates the presence of bone metastases, the overall radiological staging will not be altered by use of bone scan ie. will remain 'M1' in the TNM staging system. However, bone scan may detect metastases outside of the CT scan range which could be clinically significant and may alter management with radiotherapy and surgical options. We hoped that this study would either confirm that we could continue to justify carrying out bone scans routinely in this patient group or to demonstrate that this study was no longer routinely warranted if CT Chest, Abdomen and Pelvis was performed. Any potential change in local guidelines would be done in collaboration with our oncology and Page 2 of 9

3 surgical colleagues and, of course, we were aware that we would need to subsequently re-audit if any changes were made. Methods and materials We used RIS to identify newly diagnosed breast cancer patients who had undergone both CT Chest, Abdomen and Pelvis and Nuclear Medicine Bone Scan between September 2013 and September patients were identified including one from the breast cancer screening programme. We then compared the reports of both studies, with particular attention to the presence or absence of bone metastases. Results CT Chest, Abdomen and Pelvis and Nuclear Medicine Bone Scan were concordant in reporting the presence or absence of bony metastasis in 17 of the 22 patients included in the study. The 1st discrepancy between the two studies involved a CT report of 'tiny sclerotic lesions in the spine- metastasis cannot be exluded.' Bone Scan was carried out the same day and concluded 'No osteoblasic metastasis.' This patient then proceeded to MRI for clarification, which stated that there was no evidence of osseous metastatic disease. In this case, it could be argued that proceeding straight to MRI spine following equivocal CT would have yielded the same diagnostic information without the radiation, time and expence of a Bone Scan. The 2nd discrepancy between the two modalities occured when the CT report stated 'no bone metastases' and the Bone Scan carried out the same day was 'suspicious for a T3 metastasis.' MRI concluded 'No definite metastases. Degenerative disease at T3.' Again, in this case, it could be said that the Bone Scan did not add diagnostic value. The 3rd discrepancy was due to CT being negative for the presence of bone metastases and Bone Scan stating 'lumbar spine activity.' MRI confirmed the absence of bone metastases. Once again, some would argue that Bone Scan did not add diagnostic value to this patients management. A further case showed the presence of bone metastases on both modalities, however, the nuclear medicine study detected a distal femoral metastasis that was outside of the Page 3 of 9

4 CT scan range and, therefore, not identified on CT. This metastasis was asymptomatic and confirmed on x-ray. Whilst this did not alter the staging or management plan in this patient, it could be argued that knowing about this metastasis was clinically relevant as it may become symptomatic in the future. The final noteworthy case occured when the bone scan was performed prior to the CT and advised a CT brain added to the chest, abdomen and pelvis as there was skull base osteoblastic activity, suspicious for metastasis. This was confirmed by CT. It should be noted that both CT chest, abdomen and pelvis and nuclear medicine study were concordant regarding the presence of bone metastases. However, if CT alone had been carried out, this asymptomatic skull base lesion may not have been detected. In the final two cases, it is apparent that the Bone Scan yielded additional diagnostic information which could become clinically relevant in the future care of the patient. This was due to the fact that the Nuclear Medicine study incorporates the whole body, whereas the CT scan range is limited. Notably, as a separate point, in these cases, the CT and Bone Scan were concordant regarding the presence of bone metastasis. Images for this section: Page 4 of 9

5 Fig. 1: Cost of CT CAP vs CT CAP plus bone scan Page 5 of 9

6 Fig. 2: Radiation dose msv CT CAP vs CT CAP plus bone scan Page 6 of 9

7 Fig. 3: Equivalent backround radiation dose CT CAP vs CT CAP plus bone scan Page 7 of 9

8 Conclusion Out of the 22 patients identified, Nuclear Medicine Bone Scan added additional diagnostic information in 2 patients, by picking up bone metastases that were outside of the scan range of a standard CT Chest, Abdomen and Pelvis and may not, otherwise, have been detected. In both cases, the bone metastases detected only on Bone Scan were asymptomatic and both had other bone metastasis on CT, ie the staging remained M1. In the case of the 3 discrepancies between the 2 imaging modalities regarding the presence or absence of bone metastasis, MRI provided clarification. 2 of these cases were postivie on Bone Scan, negative on CT and MRI. 1 case was postitive on CT but negative on Bone Scan and MRI. It could, therefore, be argued that where CT is equivovcal, the patient should proceed directly to MRI of the bony area in question. Of course, CT and MRI cannot match Bone Scan in terms of their routine scan range. If protocol changed, it would have to be accepted that, as bone scan was not routinely performed, there may be further indidvdual bone metastases which are not detected. However, there should not be cases whereby the CT fails to detect bone metastases which would have been identified on Bone Scan. With regards to local protocol, we intend to liase with our multi-disciplinerary colleagues prior to implementing any change ie. removing routine use of Nuclear Medicine Bone Scan in newly diagnosed breast cancer patients with 4 or more nodes involved at time of diagnosis. Of course, we would still expect individual cases where clinical findings dictate that Bone Scan is warranted, however this would no longer be carried out routinely. We hope that this portential change in local protocol saves time, money and radiation dosage. Personal information Fiona McCloskey, ST2 Radiology, Altnagelvin Hospital, Derry, Northern Ireland mccloskf@tcd.ie Michael Reilly, Radiology Consultant, Altnagelvin Hospital, Derry, Northern Ireland Kelly Reilly, F2, Altnagelvin Hospital, Derry, Northern Ireland Page 8 of 9

9 References 1. irefer Guidelines; making the best use of clinical radiology, Royal College of Radiologists Page 9 of 9

CT findings in Differential Diagnosis between Tuberculous Pleurisy and Malignant Effusion

CT findings in Differential Diagnosis between Tuberculous Pleurisy and Malignant Effusion Poster No.: E-0084 Congress: ESTI 2012 Type: Scientific Exhibit Authors: S. S. Shim, Y. Kim; Seoul/KR Keywords: