1. FDG PET/CT has limited value for detecting primary breast cancers or axillary lymph node metastases due to low sensitivity. 2. It can help identify unsuspected extra-axillary lymph node metastases or distant metastases, which changes patient staging and management. 3. Incidentally detected FDG-avid breast lesions on PET/CT require further evaluation to determine if malignant.

1. PET/CT for Patients With Breast
Cancer: Where Is the Clinical
Impact?
Presentan : dr.Agung Wibowo Andreas
Pembimbing : dr.Nopriwan, Sp.KN(K)
PPDS 1 Radiologi
Fakultas Kedokteran Universitas Diponegoro
RSUP Dr. Kariadi Semarang
2020

2. Introduction
• Breast Cancer :
- the leading cause of cancer-related death in women
- nearly 270,000 cases will be diagnosed in 2019
- over 40,000 deaths will be attributable to breast cancer in US
• 1 in 8 women  will develop invasive breast cancer during her lifetime.
• 18F-FDG PET / CT : important clinical effect for appropriate patients.
• This article : review the use of FDG PET/CT in Breast Ca patients, method for performing FDG
PET/CT, and evidence to date suggesting where FDG PET/CT is valuable for specific clinical
applications (systemic staging of newly diagnosed locally advanced disease, monitoring of
treatment response in metastatic disease, and detection of suspected disease recurrence).

3. Performance of FDG PET / CT in Patients With Breast Cancer
• The Society of Nuclear Medicine and Molecular Imaging guidelines : recommendations for
patient preparation before FDG PET/CT to optimize the distribution of FDG in the body and
performance of the examination (Table 1).
• CT component of PET / CT is usually performed as low-dose CT scan with oral contrast
agent, but without IV contrast agent.
• Some centers and cases : full-dose CT scan with oral and IV contrast agent.
• Motion during image acquisition  can reduce resolution.
• Detection of small lesions at PET depends on : FDG avidity, lesion size, and patient
motion.

4. Performance of FDG PET / CT in Patients With Breast Cancer
PET / CT Steps Guidelines
Patient preparation - Avoid exercise the day before the
examination to prevent muscular uptake
- Do not consume food or liquids other than
unflavored water for at least 4 hours before
FDG administration
- Hydration before the scan will dilute
excreted FDG in the urine
- Keep patient warm to prevent FDG-avid
brown fat
- Blood glucose level < 200 mg/dL to prevent
altered FDG biodistribution

5. Performance of FDG PET / CT in Patients With Breast Cancer
PET / CT Steps Guidelines
FDG administration - Administer FDG IV with the patient sitting or
lying comfortably to minimize muscular uptake
- Administer in the upper extremity contralateral
to the primary breast malignancy to prevent
artifacts in the ipsilateral axilla
Performance of Scan - Patient should void before being positioned on
the PET/CT scanner to remove excreted FDG in
the urine
- PET usually begins about 60 minutes after FDG
administration FOV is usually the mid skull to
mid thigh

6. Performance of FDG PET / CT in Patients With Breast Cancer
• Quantitation of FDG avidity : performed with Standardized Uptake Value (SUV)
• SUV : measurement of tracer uptake in a lesion normalized to distribution volume.
• SUV = tracer uptake in ROI / (injected activity / patient weight).
• Many different forms of SUV, depending on :
- how the SUV is normalized (weight, lean body mass, or body surface area)
- how the ROI is analyzed (maximum, mean, or peak SUV).

7. Initial Staging
• Clinical staging of Breast Vancer is based on the American Joint Committee on Cancer’s
TNM staging system  imaging plays a central role.
• All patients with Breast Cancer should be assigned a clinical stage of disease, because
staging assists in determining local and systemic treatment and provides prognostic
information.
• Loco-regional Breast Ca  5 year survival rates 76 - 99%.
• Breast Ca + distant metastases  5 year survival rates 20 - 28%.
• Mammography, USG, breast MRI : accurate staging local disease extent.
• Bone scan, abdominal CT / MRI, chest CT, and FDG PET/CT : role in systemic staging.
• FDG PET/CT : important clinical effect for appropriate Breast Ca patients (not all).

8. The Primary Breast Tumor
• Breast imaging (mammography, USG, breast MRI) : the mainstay of evaluation of breast
lesions.
• Whole-body FDG PET/CT : low sensitivity for the primary breast tumor.
• Neither FDG PET nor CT is sensitive enough to detect breast cancers smaller than 1 cm.
• Several Breast Ca histologic sub types (especially lobular breast cancers) : have lower
FDG avidity than ductal breast malignancies (the most common)
• Lobular Breast Ca may be occult at FDG PET, even at large sizes.

9. The Primary Breast Tumor
• FDG PET/CT also has low specificity within the breast.
• Inflammatory condition (post surgical inflammation, granulomatous processes, infections)
may be markedly FDG avid.
• Benign tumors (fibroadenoma) may be FDG avid.

10. The Primary Breast Tumor
• Physiologic breast tissue (lactating patient) may be substantially FDG avid  should
not be mistaken for malignant or infectious process.
• Combination of low sensitivity and specificity in breast limits the value of whole-body
FDG PET/CT for initial detection of a primary breast malignancy, as well as for
discrimination of benign and malignant breast lesions.
• Patients with known primary breast malignancy  FDG-avid breast soft tissue lesion is
of course the known primary malignancy.

11. The Primary Breast Tumor
• Incidentally identified FDG-avid breast soft-tissue lesions (discovered during imaging of
patient with non breast malignancy) have 30 - 40% chance of being malignant (Fig.1).
• These include : previously unsuspected primary breast malignancies, metastases
to the breast, and breast lymphoma.
• Incidentally identified FDG-avid breast soft-tissue lesions  further evaluated by
mammography and/or USG  suspicious characteristics lesion  should prompt
biopsy.

12. The Primary Breast Tumor
Fig. 1 : 46 years old woman with Ovarian Cancer and incidentally detected FDG-avid breast focus, subsequently
determined to be unsuspected primary breast cancer.
Left : Axial fused FDG PET/CT shows FDG-avid focus in right breast (arrow). Mammogram was normal (not shown).
Right : Breast USG : 0.8 cm hypoechoic mass (arrow). Ultrasound-guided biopsy : Invasive Ductal Breast Cancer.

13. The Primary Breast Tumor
• Nuclear medicine of Primary Breast Lesions  improved by development of dedicated
breast PET systems and dedicated single-photon gamma imaging systems of the breast
(Narayanan and Berg).
• Positron Emission (PE) Mammography : far more sensitive than whole-body FDG
PET/CT for detection of primary breast malignancies and additional ipsilateral breast
tumors.
• Breast MRI :
- has greater sensitivity than PE mammography
- the mainstay of detailed breast imaging
• Dedicated breast Nuclear Imaging (Positron Emission mammography)  should be
considered when MRI is contraindicated.

14. Locoregional Nodal Metastases
• For evaluation of Breast Cancer locoregional nodal metastases  FDG PET/CT make
distinction between axillary and regional extraaxillary nodes.
• Mainstay of axillary nodal staging for over 2 decades has been sentinel lymph node biopsy.
• Sentinel node :
- Identified in over 97% of Breast Ca patients (use of blue dye or radioactive tracers).
- Removed surgically  detailed pathologic evaluation.
- > 95% prediction of disease status of remaining axilla.
• Compared with sentinel node biopsy :
FDG PET/CT has poor sensitivity for axillary nodal metastases.

15. Locoregional Nodal Metastases
• Clinically relevant axillary nodal metastases often sub-centimeter in size  FDG
PET/CT be inferior to Pathologic evaluation.
• The specificity of FDG PET/CT for axillary nodes has been shown to be far better than its
sensitivity.
• The presence of FDG-avid axillary node is likely to represent nodal malignancy.
• Causes of false-positive FDG avidity : post axillary procedural inflammation, tracer
extravasation at upper extremity  highlighting of upper extremity sentinel node (not
containing malignancy)  Fig. 2

16. Locoregional Nodal Metastases
Fig. 2 : Artifactual FDG avidity in axillary node secondary to extravasation of tracer at injection site.
A. Axial FDG PET (left), bone window CT (middle), and fused FDG PET/CT (right) show : FDG-avid focus
(arrows) corresponding to tiny left axillary node.

17. Locoregional Nodal Metastases
Fig. 2 : Artifactual FDG avidity in axillary node secondary to extravasation of tracer at injection site.
B. FDG maximum-intensity-projection image : FDG-avid axillary node (black arrow) is probably due to
drainage from extravasation of tracer at injection in ipsilateral arm (white arrow).

18. Locoregional Nodal Metastases
• Locoregional extra axillary nodes (internal mammary, infraclavicular, supraclavicular
nodes) :
- clinically occult, less commonly identified
- FDG PET/CT show value in patient staging with unsuspected extra axillary nodal
metastases
• Identification of unsuspected extraaxillary nodal metastases at initial staging 
- influences assignment of patient stage and prognosis
- alter local therapy by altering the extent of local surgery or Radiotherapy.

19. Distant Metastases
• Conventional imaging for distant metastases of Breast Ca : anatomic imaging (body CT)
and functional bone imaging (methylene diphosphonate or similar gamma radiotracer bone
scintigraphy, or 18F-NaF PET/CT).
• Recently : more-comprehensive functional imaging with FDG PET/CT has been used.
• FDG PET/CT can identify previously unsuspected distant metastases in patients with locally
advanced breast cancer.
• Detection of previously unsuspected distant metastases has substantial clinical effect 
changing patient’s stage from only locoregional disease to stage IV (Fig. 3).
• This converts patient management : curative-intent therapy (surgery with/without
neoadjuvant) to palliative therapies.

20. Distant Metastases
Fig.3 43 years old woman with pre-PET/CT stage IIB Invasive Ductal breast cancer and previously unsuspected
distant metastases.
A. FDG maximum intensity projection shows previously known primary left breast malignancy (long black arrow),
previously known left axillary nodal metastases (white arrows), and FDG-avid foci overlying liver (short black
arrows). Avidity adjacent to both hip joints was benign and related to bilateral hip prostheses.

21. Distant Metastases
Fig.3 43 years old woman with pre-PET/CT stage IIB Invasive Ductal breast cancer and previously unsuspected
distant metastases.
B. Axial fused FDG PET/CT (left) and CT scan (right) : previously known primary left breast malignancy (black
arrows) and previously known left axillary nodal metastases (white arrows).

22. Distant Metastases
Fig.3 43 years old woman with pre-PET/CT stage II B Invasive Ductal breast cancer and previously unsuspected
distant metastases.
C. Axial fused FDG PET/CT (left) and CT images in liver window (right) localize FDG-avid focus (arrows) to low-
attenuation liver lesion (subsequently biopsy proven : liver metastasis). This changed patient’s initial stage to IV.

23. Distant Metastases
• The detection rate of unsuspected distant metastases by FDG PET/CT increases as the pre-
PET/CT local stage increases.
• Prospective study of 254 consecutive patients (Groheux et al.) reported unsuspected distant
metastases in :
- one of 44 (2%) patients with stage II A
- 6 of 56 (11%) patients with stage II B
- 11 of 63 (18%) patients with stage III A
- 27 of 74 (37%) patients with stage III B
- 8 of 17 (47%) patients with stage III C
• Markers of higher-risk breast cancer (younger patient age, tumors negative for estrogen
receptor (ER), progesterone receptor, and human epidermal growth factor receptor 2 / HER2),
 increase the yield of detecting distant metastases at earlier stages.

24. Distant Metastases
• Rate of additional disease detection by FDG PET/CT greater than body CT bone imaging.
• FDG PET/CT is more accurate for detection of osseous metastases (with pathologic
analysis standard) than body CT bone imaging (Fig. 4).
• FDG PET/CT provided diagnosis better matching the pathologic result.
• FDG PET/CT may render bone scintigraphy unnecessary in Breast Ca patients.

25. Distant Metastases
Fig. 4 : 51 years old woman with pre-PET/CT stage IIIA invasive ductal breast cancer and osseous metastasis
missed by CT bone scan.
A. FDG maximum intensity projection : known primary left breast malignancy (black arrow) and FDG-avid
focus near right pelvis (white arrow).

26. Distant Metastases
Fig. 4 : 51 years old woman with pre-PET/CT stage IIIA invasive ductal breast cancer and osseous metastasis
missed by CT bone scan.
B. Axial CT (left) and fused FDG PET/CT (right) images show that focus near pelvis (arrow, right) localizes to
right femoral head, without clear CT correlate.

27. Fig. 4 : 51 years old woman with pre-PET/CT stage III A invasive ductal breast cancer and
osseous metastasis missed by CT bone scan.
C. Methylene diphosphonate bone scan does not detect lesion. Subsequent biopsy proved
osseous metastasis, which was apparent at FDG PET/CT but would not have been apparent at
CT/bone scan only. R = right, L = left.

28. Distant Metastases
• The most common organ systems for distant metastases in Breast Cancer : bone, lymph
nodes, liver, and lung.
• Several FDG-avid tumor mimics in those organs  should be recognized and distinguished
from malignancy  increase the specificity of FDG PET/CT.
• Mimic in bone : bone marrow repopulation from colony-stimulating factors, fractures,
avascular necrosis, Paget disease, benign neoplasms, systemic inflammatory diseases, and
iatrogenic injuries.
• Should be distinguished from malignancy by correlation with clinical history, distribution
of avidity, and findings on the corresponding CT images.
• Mistaking Paget disease of bone for osseous metastasis  lead to unnecessary biopsy
(Fig. 5).

29. Distant Metastases
Fig. 5 : 72 years old woman with pre-PET/CT stage III A invasive ductal breast cancer and Paget disease.
A. Axial CT in soft-tissue window (left) and fused FDG PET/CT (right) show known left breast malignancy (arrows).

30. Distant Metastases
Fig. 5 : 72 years old woman with pre-PET/CT stage III A invasive ductal breast cancer and Paget disease.
B. Sagittal CT bone window (left) and sagittal fused FDG PET/CT (right) : FDG-avid L4 vertebra (arrows). CT :
bone enlargement, thickening of cortex, and coarsening of trabeculae, consistent with benign Paget disease,
preventing misidentification as osseous metastasis  The use of CT increases specificity of diagnosis for FDG-
avid lesions on FDG PET/CT.

31. Distant Metastases
• Summary of the sensitivity and specificity of FDG PET/CT for the primary breast metastases
at initial diagnosis  in Table 2.
• Although FDG PET/CT performs poorly compared with mammography, ultrasound, breast
MRI, and axillary nodal pathologic evaluation for early disease, it becomes increasingly
useful for later disease, particularly extraaxillary nodal and distant metastases.
• The use of FDG PET/CT should be targeted to patients at higher risk of advanced
disease.

32. Distant Metastases
Lesion Type Sensitivity Specificity
Primary Tumor Low Low
Axillary Lymph nodes Low (compared with axillary
lymph node biopsy)
High
Extra Axillary Lymph
nodes
High High
Metastases High High (using CT to recognize
many benign causes of FDG
avidity)

33. Distant Metastases
• Detection rate of extra-axillary nodal metastases and distant metastases (with FDG PET/CT)
at initial : greatest in stage III disease  the greatest clinical effect.
• Patients with stage II B disease after mammography, ultrasound, or breast MRI have lower,
but still potentially clinically significant, rates of detection for unsuspected more-advanced
disease.
• Rates of upstaging in stage I and II A disease are too low to consider FDG PET/CT.

34. Distant Metastases
• Detection of unsuspected distant metastases by FDG PET/CT at initial staging not
conclusively shown to improved patient outcomes.
• Improved initial staging of patients at diagnosis  result in apparent improvement in
stage-specific survival through stage migration phenomenon.
• Detection by screening, use of FDG PET/CT, improvements in therapy  Breast Ca
mortality by stage has been decreasing at recent years.

35. Neoadjuvant Therapy Response in the Primary
Breast Malignancy
• Neoadjuvant chemotherapy (NAC) :
- initially used to make some inoperable Breast Ca become resectable
- recently used even for operable tumors  to downstage disease, facilitate breast
conservation, or avoid axillary nodal dissection.
• Studies : Strong correlation between early changes in FDG maximum SUV and NAC
response at pathologic examination
• More recent studies : criteria for predicting NAC response in tumors of varying receptor status
according to several measures of FDG avidity (Groheux, et al).
• Breast MRI, Mammography, USG, and physical examination  can be used to distinguish NAC
response from non response.

36. Neoadjuvant Therapy Response in the Primary
Breast Malignancy
• No modality (including PET) can distinguish partial response from complete response
• Low volume residual disease may persist despite no evidence of disease at imaging.
• Pathologic examination can asses partial response and complete response.
• All Breast Ca patients will proceed to surgical resection after NAC, and Pathologic Exam
available to define NAC treatment response  clinical value of FDG PET in predicting the
NAC response is limited.

37. Treatment Response in Metastatic Disease
• Current standard of measuring treatment response in metastatic Breast Cancer : size
measurements of tumors at CT.
• Metabolic changes by FDG PET : better predict treatment response than anatomic changes.
• Initial studies of FDG PET in the evaluation of breast cancer metastases found that FDG
PET could assess response versus non response after only one to three cycles of therapy.

38. Treatment Response in Metastatic Disease
• More recent studies  the ability to distinguish response from non-response, which applied
to distinct and varied courses of hormonal and chemotherapies.
• Studies of hybrid FDG PET/CT have found that FDG PET was superior to CT in showing
response in osseous metastases.
• FDG PET is able to detect osseous metastases earlier than CT.
• Accurate therapy response assessment at FDG PET/CT :
Sclerotic lesions at CT post therapy  represent osseous healing (not new metastases)
(Fig. 6).

39. Treatment Response in Metastatic Disease
Fig. 6 : 41 years old woman with metastatic invasive ductal breast cancer.
A. Axial CT in bone window (left) and fused FDG PET/CT (right) : FDG-avid focus in sacrum, without CT
correlate (arrow, right).

40. Treatment Response in Metastatic Disease
Fig. 6 : 41 years old woman with metastatic invasive ductal breast cancer.
B. After systemic therapy : FDG avidity resolves. New sclerotic lesion (arrows) on axial CT (left) and fused
FDG PET/CT (right). On CT  could represent either benign osteoblastic remodeling after successful
therapy or new osseous metastasis.
Resolution of FDG avidity more confidently showed : this is benign osteoblastic remodeling.

41. Treatment Response in Metastatic Disease
• Increasing avidity (at bone scan) may represent either increased osseous malignancy or
increased osteoblastic response during bone healing after successful therapy 
Bone scan is limited in therapy response evaluation in osseous lesions.
• Osteoblastic flare response (bone scan) : persist for several months.
• Metabolic flare is seen at FDG PET, and temporarily increasing FDG avidity after successful
therapy.
• Metabolic flare (FDG PET) usually in first 1–2 weeks  not confounding issue on bone scan
that usually performed months after initiating therapy.
• FDG metabolic flare : indicator of future response to therapy.
• The question : Metabolic response might depend on number of lesions selected for
determining response ?

42. Treatment Response in Metastatic Disease
• Recent study : Either one or five lesions for response assessment not have major influence
on prognostic value of follow-up FDG PET/CT.
• Among 65 patients with metastatic breast cancer, metabolic assessment by FDG PET/CT was a
better predictor of both progression-free and disease-specific survival than was Response
Evaluation Criteria in Solid Tumors evaluation at CT (Fig. 7).
• Although further work is needed, this finding suggests that there is incremental clinical value
for FDG PET/CT in therapy response for patients with metastatic breast cancer.

43. Treatment Response in Metastatic Disease
Fig. 7 : Graph of disease-specific survival for 65 patients who underwent both contrast-enhanced CT and FDG
PET/CT evaluation of treatment response.
Response on FDG PET/CT was superior predictor of disease-specific survival than was response on contrast-
enhanced CT.

44. Suspected Disease Recurrence
• Patient suspected having recurrence of malignancy by clinical symptom, physical
examination, or elevated serum marker  imaging be performed (further evaluation).
• FDG PET/CT : useful for evaluation of suspected disease recurrence and compares favorably
with other imaging modalities (CT, bone scan, whole-body MRI).
• Recent study of 100 women with suspected Breast Ca recurrence prospectively :
Diagnostic accuracy of FDG PET/CT better than Contrast-Enhanced CT or
Contrast-Enhanced CT + Bone Scan for disease recurrence.

45. Does Receptor Status, Tumor Grade, or Histologic
Type Affect FDG PET/CT Interpretation?
• The term “breast cancer” : wide range of biologically different lesions (classified by WHO).
• Histologic types of Breast Ca : infiltrating ductal carcinoma / IDC (75 - 80%), and infiltrating
lobular carcinoma / ILC (10 - 15%).
• Breast Ca grading : how much the cancer cells look like normal cells.
• Lower grade : the cancer is more similar to normal cells.
• Higher grade : the cancer is unlike normal cells.
• The terms “well differentiated,” “moderately differentiated,” and “poorly differentiated” are also
used to depict grades of 1, 2, and 3.
• Higher-grade malignancies : grow more rapidly.

46. Does Receptor Status, Tumor Grade, or Histologic
Type Affect FDG PET/CT Interpretation?
• Molecular genetic classifications distinguish intrinsic subtypes of Breast Ca according to
gene expression patterns : luminal, HER2-positive, and basal-like breast cancers.
• Standard categorization of clinical care : Immunohistochemical receptor expression in ER
positive HER2-negative, HER2-positive, and triple-negative breast cancer.
• FDG avidity of Breast Ca is influenced by receptor status, grade, and histologic type.
• ER-negative tumors : statistically significant higher FDG avidity than ER-positive
tumors.
• Grade 3 Ca : statistically significant higher FDG avidity than do lower-grade
malignancies.

47. Does Receptor Status, Tumor Grade, or Histologic
Type Affect FDG PET/CT Interpretation?
• Primary ILC lesions and ILC metastases : lower FDG avidity than IDC lesions.
• Untreated osseous metastases from ILC are more likely to be sclerotic and to be missed
by FDG PET than are IDC metastases because of their avidity being no higher than
background (Fig. 8).

48. Does Receptor Status, Tumor Grade, or Histologic
Type Affect FDG PET/CT Interpretation?
Fig. 8 : 56 years old woman with locally advanced invasive lobular breast cancer. Beware of non-FDG-avid
metastases in ILC.
Axial FDG PET (left), CT in bone window (middle), fused FDG PET/CT (right) not show suspicious FDG-avid foci,
but multiple osseous sclerotic lesions on CT (arrows, middle) are suggestive of metastases.
Biopsy confirmed osseous metastasis.

49. Does Receptor Status, Tumor Grade, or Histologic
Type Affect FDG PET/CT Interpretation?
• Why FDG PET/CT has lower rates of detecting distant metastases in ILC than in IDC ?
• Patterns of metastatic spread in ILC : tend to metastasize to GI tract and
Retroperitoneum (difficult to assess with FDG PET because common sites of
physiologic and variable FDG avidity).
• Osseous and visceral metastases in ILC are commonly can not be detected on FDG PET 
need to detect on CT component of the study.

50. Male Breast Cancer
• Breast Ca in men : around 1% of all Breast Ca.
• No screening guidelines for detection of Breast Ca in men  Male Breast Ca often
detected at more advanced stages than in women (including larger primary tumor sizes
and more nodal involvement, and higher grade).
• Male Breast Ca almost always Ductal histologic type and ER positive.
• Male Breast Ca is rare  very limited data on FDG PET/CT.
• 92 male with Breast Ca (four studies) : 56 underwent FDG PET/CT (initial staging) 
rates of upstaging were comparable to rates in women.
• No sex-specific guidelines for the use of FDG PET/CT in men currently exist.

51. Developing Radiotracers and PET/MRI
• FDG PET/CT show : value in initial staging, assessing treatment response, evaluation of
suspected recurrence, dan prognostic guidance.
• Prognostic guidance : because FDG PET/CT has higher FDG avidity by multiple
investigators to correlate with poorer outcomes.
• FDG PET/CT application now : prognostic applications (distinguish tumors with intrinsically
good or poor prognosis)
• Next generation applications of FDG PET/CT may include :
Novel predictive applications (determining which therapies will be effective in a patient)

52. Developing Radiotracers and PET/MRI
• Choice of optimal therapeutics : Novel agents targeting ER, Progesterone
receptor, and HER2.
• Kurland et al. : potential using 18F-fluoroestradiol PET in conjunction with FDG PET
to predict response to endocrine therapy.
• HER2-targeted imaging : show patients with HER2-positive metastases, which
respond to HER2-targeted therapy (Primary tumor can be HER2-negative).
• There are more PET radiotracers used in Breast Ca.

53. Developing Radiotracers and PET/MRI
• Amino acid tracers (18F-Fluciclovine) : useful for Lobular Breast Ca.
• PET/MRI : growing area of investigation in Breast Ca patient (Melsaether and
Moy).
• MRI component of PET/MRI provides high sensitivity for primary breast tumor.
• For systemic staging, PET/MRI may have better sensitivity for liver and osseous
metastases, but PET/CT trends toward better detection of pulmonary metastases.

54. Terimakasih