Bone scanning and early breast cancer: five-year follow-up

The management of operable breast cancer in Scotland surgeons' opinions. The Scottish Cancer Trials Breast Group

This report gives the responses of general surgeons in Scotland to two questionnaires. Satisfactory rates were obtained: 82% for the more detailed survey in 1988 and 62% for the second survey (1991), where nonrespondents were not followed up. In 1988 the rationale was the poor participation in the Scottish breast conservation trial while the 1991 survey further investigated the diversity of surgical opinion identified in the first. The limited trial support in 1988 was mainly due to reluctance to accept all treatment options. The majority were prepared to consider trial participation although 47% believed this compromised doctor-patient relationships. Although breast-conserving therapy was widely supported, many different views on management were encountered, both in the degree of influence of specific factors and in the decisions taken in relation to them. We believe these surveys have re-inforced a need for management guidelines, particularly as around half the patients with symptomatic breast cancer were being treated in non-specialist units.

MCA Serum Determination in Breast Carcinoma Patients for the Diagnosis of Bone Metastases

Serum MCA levels were determined in 173 consecutive patients with breast cancer in order to assess the clinical utility of MCA for the detection of bone metastases. Bone pathology was diagnosed by scintigraphy, radiology and clinical follow-up. Metastases were found in 37 patients, benign lesions in 25, and in 111 no bone lesions were found. Eighteen of the 173 bone scans were considered indeterminate for metastases. Based on the receiver-operating characteristic curves (ROC) analysis, the cut-off level for MCA was set at 20 U/ml. Only in 4 of the 37 patients with bone metastases MCA was below 20 U/ml. All 4patients had completed their chemotherapy course within six months before MCA determination. Only in 6 patients of the 136 without bone metastases MCA levels were above 20 U/ml. Of the 18 patients with indeterminate bone scans, 15 had benign lesions and all of them had MCA levels below 20 U/ml.

MCA determination is a sensitive method for the detection of bone metastases in breast carcinoma. We encourage the use of this procedure for the selection of high-risk groups or as a complementary method for the interpretation of bone scintigraphy.

24 hour/3 hour radio-uptake technique for differentiating degenerative and malignant bony lesions in bone scanning

Differentiating bony metastases from degenerative lesions is of great importance to the oncologist. Routine bone scanning using technetium-99m methylene diphosphonate is the investigation of choice for detecting bony lesions, but its specificity is low. Using the difference in radio-uptake behaviour of metastatic and degenerative lesions as the criterion, a 24/3 h radio-uptake, lesion to non-lesion ratio was used to separate out the two types of lesions. Radio-uptake ratio (RUR) distribution curves of malignant and degenerative lesions were found to be significantly different (P < 0.001). Taking 1.12 as the critical point, RUR of malignant lesions was found to be more than the critical point, and that of degenerative lesions was found to be less than the critical point. Sensitivity, specificity and accuracy were found to be 68%, 80% and 74%, respectively.

Bone scintigraphy in breast cancer: a nine-year follow-up

The results of skeletal scintigraphy performed at presentation in 465 women with histologically confirmed carcinoma of the breast were correlated with tumour size, node status, clinical course and survival during a follow-up of at least 2 years and up to 9 years. Skeletal metastases were eventually confirmed in 17.6% of the population under study, but were identified at presentation by scintigraphy in only half of these. The incidence of significant scintigraphic abnormalities ranged from 1.5% in patients with T0 and T1 node negative tumours to 20.3% in T4 node positive tumours. Patients with scintigraphic evidence of metastases had a significantly shorter survival than those without; 13.6% of the patients with an abnormality considered to be significant on the criteria employed in this study failed to develop confirmatory evidence of skeletal metastases during the period of follow-up. Alternative criteria are proposed which would substantially decrease the incidence of false positives without increasing the incidence of false negatives. Even so, it is concluded that there is no evidence that routine skeletal scintigraphy affects management of newly diagnosed patients with carcinoma of the breast. Unless an algorithm can be defined which requires the information provided by skeletal scintigraphy in order to determine clinical management, this investigation is not justified as a routine staging procedure and should be reserved for patients in whom there is a clinical suspicion of metastases and for clinical trials.

Value of bone scanning in neoplastic disease

This article reviews recent literature on a variety of primary and secondary bone tumors in an attempt to indicate the use of bone scans in the peri- and posttreatment phases. The data indicate that the yields and value of bone scans are tumor specific and that for some tumors (particularly breast and prostate) interpretation of studies on patients undergoing hormonal or chemotherapy can be complicated by the "flare phenomenon." Data are still needed on the rate of development of bone metastases in the follow-up period on a stage-specific and therapy-specific basis.

Detection of breast carcinoma metastases in bone: relative merits of X-rays and skeletal scintigraphy

Of 1116 patients receiving primary treatment for breast carcinoma at the Royal Marsden Hospital since 1976, 651 had an abnormal bone scintigram either at primary diagnosis (378) or on subsequent follow-up (273) and 167 developed radiographically detectable bone metastases (21 at the time of primary diagnosis). Comparison of bone scintigrams and X-rays showed that scintigraphy was an inaccurate localiser of existing radiographic detectable metastases. If X-rays alone are used to detect bone metastases a limited examination with five plates will detect metastases with 92% accuracy. After primary surgery, routine X-ray screening for bone metastases is not necessary since it is possible to identify patients at risk on the basis of clinical examination, chest X-ray, and serum alkaline phosphatase and gamma-glutamyl transpeptidase levels.