1. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer Early detection of disease Precise Staging of Disease Progression Accurate Assessment of Therapy

2. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Breast Cancer 31% of all new malignancies in women, 7% in men Mammographic screening improves early detection and survival Types  Ductal85%  Lobular 10% TNM staging is used Combined modality treatment is common

3. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer Diagnosis Staging Restaging

4. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Diagnosing Breast Cancer History 50 YOF Palpable (barely) mass in left breast; doctor not concerned Dense breasts, mammogram normal PET Findings Hyper-metabolic breast focus in left breast Outcome Surgical resection Stage I breast cancer

5. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in the Diagnosis of Breast Cancer 117 patients with suspected breast cancer PET compared with histopathology PET  Sensitivity 93%  Specificity 75% PET detected multi-focal cancer better than mammography PETMammo  Multi-focal 63% 32% Detection Schirrmeister H EJNM 2001; 28:351.

6. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Why PET for diagnosis? Dense breast tissue on mammogram Multiple abnormalities Equivocal biopsy results Breast implant

7. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer Diagnosis Staging Restaging

8. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Staging Breast Cancer History 57 YOF Right breast cancer Elevated tumor markers PET Findings Hyper-metabolic right breast cancer and axillary nodes Outcome Primary chemotherapy Surgery deferred mets primary

9. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Axillary Node Staging 167 patients with biopsy proven breast cancer Pre-operative PET compared to results of axillary node resection PET  Sensitivity 94%  Specificity 86% Greatest sensitivity in patients with tumor >2cm Greco M Natl Cancer Inst 200; 93;630.

10. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Why stage with PET? Locally advanced cancers anticipating primary chemotherapy Breast cancers arising medially drain into internal mammary nodes Suspected multi-focal cancers Indeterminant clinical, imaging or pathologic findings

11. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer Diagnosis Staging Restaging  Recurrence detection  Recurrence extent  Therapy assessment

12. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Detecting Recurrence History 57 YOF Breast cancer 5 years ago, primary is gone Presented with elevated markers Mammo negative CT negative Bone scan negative PET Findings Left supraclavicular node uptake Outcome Biopsy proven metastasis XRT & chemotherapy normal GI activity

13. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Detecting the Extent of Recurrence History 49 YOF Breast cancer 7 years ago Presented with elevated markers Asymptomatic PET Findings Numerous skeletal and liver foci Outcome Biopsy proven mets High dose chemotherapy Stem cell replacement

14. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Detection of Recurrent or Metastatic Breast Cancer 27 patients suspected recurrence PET compared with biopsy PET  Sensitivity 94%  Specificity 80% Lesion detection rate 94% 13 of 27 PET results altered treatment KimTS World J Surg. 2001;25;829.

15. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET in Breast Cancer History 55 YOF Left breast cancer PET Findings Marked improvement with primary chemotherapy Outcome Complete response to treatment Before Treatment After Treatment

16. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. Response to Primary Chemotherapy 30 patients with advanced stage breast cancer Primary chemotherapy & serial PET scans Prediction (before surgery) of pathologic CR (complete remission) PET  Sensitivity 90%  Specificity 74% PET predicted CR after single cycle of chemotherapy Smith IC J Clin Oncol 2000; 18:1676.

17. © Copyright 2003 Cardinal Health, Inc. or one of its subsidiaries. All rights reserved. PET is an important adjunct in the diagnosis and staging of breast cancer PET is superior to all imaging modalities in the restaging of breast cancer Difficult patient management problems can often be solved with the unique information PET provides PET in Breast Cancer