Standardized uptake value by positron emission tomography/computed tomography as a prognostic variable in metastatic breast cancer

Joint EANM-SNMMI guideline on the role of 2-[18F]FDG PET/CT in no special type breast cancer : (endorsed by the ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA)

INTRODUCTION

There is much literature about the role of 2-[18F]FDG PET/CT in patients with breast cancer (BC). However, there exists no international guideline with involvement of the nuclear medicine societies about this subject.

PURPOSE

To provide an organized, international, state-of-the-art, and multidisciplinary guideline, led by experts of two nuclear medicine societies (EANM and SNMMI) and representation of important societies in the field of BC (ACR, ESSO, ESTRO, EUSOBI/ESR, and EUSOMA).

METHODS

Literature review and expert discussion were performed with the aim of collecting updated information regarding the role of 2-[18F]FDG PET/CT in patients with no special type (NST) BC and summarizing its indications according to scientific evidence. Recommendations were scored according to the National Institute for Health and Care Excellence (NICE) criteria.

RESULTS

Quantitative PET features (SUV, MTV, TLG) are valuable prognostic parameters. In baseline staging, 2-[18F]FDG PET/CT plays a role from stage IIB through stage IV. When assessing response to therapy, 2-[18F]FDG PET/CT should be performed on certified scanners, and reported either according to PERCIST, EORTC PET, or EANM immunotherapy response criteria, as appropriate. 2-[18F]FDG PET/CT may be useful to assess early metabolic response, particularly in non-metastatic triple-negative and HER2+ tumours. 2-[18F]FDG PET/CT is useful to detect the site and extent of recurrence when conventional imaging methods are equivocal and when there is clinical and/or laboratorial suspicion of relapse. Recent developments are promising.

CONCLUSION

2-[18F]FDG PET/CT is extremely useful in BC management, as supported by extensive evidence of its utility compared to other imaging modalities in several clinical scenarios.

An Innovative Non-Linear Prediction Model for Clinical Benefit in Women with Newly Diagnosed Breast Cancer Using Baseline FDG-PET/CT and Clinical Data

Objectives: We aimed to develop a novel non-linear statistical model integrating primary tumor features on baseline [18F]-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT), molecular subtype, and clinical data for treatment benefit prediction in women with newly diagnosed breast cancer using innovative statistical techniques, as opposed to conventional methodological approaches. Methods: In this single-center retrospective study, we conducted a comprehensive assessment of women newly diagnosed with breast cancer who had undergone a FDG-PET/CT scan for staging prior to treatment. Primary tumor (PT) volume, maximum and mean standardized uptake value (SUVmax and SUVmean), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured on PET/CT. Clinical data including clinical staging (TNM) but also PT anatomical site, histology, receptor status, proliferation index, and molecular subtype were obtained from the medical records. Overall survival (OS), progression-free survival (PFS), and clinical benefit (CB) were assessed as endpoints. A logistic generalized additive model was chosen as the statistical approach to assess the impact of all listed variables on CB. Results: 70 women with newly diagnosed breast cancer (mean age 63.3 ± 15.4 years) were included. The most common location of breast cancer was the upper outer quadrant (40.0%) in the left breast (52.9%). An invasive ductal adenocarcinoma (88.6%) with a high tumor proliferation index (mean ki-67 expression 35.1 ± 24.5%) and molecular subtype B (51.4%) was by far the most detected breast tumor. Most PTs displayed on hybrid imaging a greater volume (12.8 ± 30.4 cm3) with hypermetabolism (mean ± SD of PT maximum SUVmax, SUVmean, MTV, and TLG, respectively: 8.1 ± 7.2, 4.9 ± 4.4, 12.7 ± 30.4, and 47.4 ± 80.2). Higher PT volume (p < 0.01), SUVmax (p = 0.04), SUVmean (p = 0.03), and MTV (<0.01) significantly compromised CB. A considerable majority of patients survived throughout this period (92.8%), while five women died (7.2%). In fact, the OS was 31.7 ± 14.2 months and PFS was 30.2 ± 14.1 months. A multivariate prediction model for CB with excellent accuracy could be developed using age, body mass index (BMI), T, M, PT TLG, and PT volume as predictive parameters. PT volume and PT TLG demonstrated a significant influence on CB in lower ranges; however, beyond a specific cutoff value (respectively, 29.52 cm3 for PT volume and 161.95 cm3 for PT TLG), their impact on CB only reached negligible levels. Ultimately, the absence of distant metastasis M displayed a strong positive impact on CB far ahead of the tumor size T (standardized average estimate 0.88 vs. 0.4). Conclusions: Our results emphasized the pivotal role played by FDG-PET/CT prior to treatment in forecasting treatment outcomes in women newly diagnosed with breast cancer. Nevertheless, careful consideration is required when selecting the methodological approach, as our innovative statistical techniques unveiled non-linear influences of predictive biomarkers on treatment benefit, highlighting also the importance of early breast cancer diagnosis.

Evaluation of Treatment Response in Patients with Breast Cancer

Breast cancer (BC) remains one of the leading causes of death among women. The management and outcome in BC are strongly influenced by a multidisciplinary approach, which includes available treatment options and different imaging modalities for accurate response assessment. Among breast imaging modalities, MR imaging is the modality of choice in evaluating response to neoadjuvant therapy, whereas F-18 Fluorodeoxyglucose positron emission tomography, conventional computed tomography (CT), and bone scan play a vital role in assessing response to therapy in metastatic BC. There is an unmet need for a standardized patient-centric approach to use different imaging methods for response assessment.

Advances in PET/CT Imaging for Breast Cancer

One out of eight women will be affected by breast cancer during her lifetime. Imaging plays a key role in breast cancer detection and management, providing physicians with information about tumor location, heterogeneity, and dissemination. In this review, we describe the latest advances in PET/CT imaging of breast cancer, including novel applications of 18F-FDG PET/CT and the development and testing of new agents for primary and metastatic breast tumor imaging and therapy. Ultimately, these radiopharmaceuticals may guide personalized approaches to optimize treatment based on the patient's specific tumor profile, and may become a new standard of care. In addition, they may enhance the assessment of treatment efficacy and lead to improved outcomes for patients with a breast cancer diagnosis.

Novel applications of molecular imaging to guide breast cancer therapy

The goals of precision oncology are to provide targeted drug therapy based on each individual’s specific tumor biology, and to enable the prediction and early assessment of treatment response to allow treatment modification when necessary. Thus, precision oncology aims to maximize treatment success while minimizing the side effects of inadequate or suboptimal therapies. Molecular imaging, through noninvasive assessment of clinically relevant tumor biomarkers across the entire disease burden, has the potential to revolutionize clinical oncology, including breast oncology. In this article, we review breast cancer positron emission tomography (PET) imaging biomarkers for providing early response assessment and predicting treatment outcomes. For 2-¹⁸fluoro-2-deoxy-D-glucose (FDG), a marker of cellular glucose metabolism that is well established for staging multiple types of malignancies including breast cancer, we highlight novel applications for early response assessment. We then review current and future applications of novel PET biomarkers for imaging the steroid receptors, including the estrogen and progesterone receptors, the HER2 receptor, cellular proliferation, and amino acid metabolism.

Prediction of Pretreatment 18F-FDG-PET/CT Parameters on the Outcome of First-Line Therapy in Patients with Metastatic Breast Cancer

Objective

18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT) can provide prognostic information, especially 18F-FDG uptake has been proven to be a predictor for the prognosis of various tumors. Nevertheless, the prognosis of other PET parameters in the metastatic setting remains unclear. This study was aimed at investigating pretreatment parameters based on 18F-FDG-PET/CT so as to estimate the progression-free survival (PFS) of metastatic breast cancer (MBC) patients receiving first-line treatment.

Methods

MBC patients who underwent a whole-body 18F-FDG-PET/CT prior to first-line therapy were enrolled. The heterogeneity parameter of PET/CT was analyzed, including heterogeneity index (HI) and general parameters (metabolic tumor volume (MTV), total lesion glycolysis (TLG), maximum standardized uptake value (SUVmax) and mean SUV (SUVmean). PFS was used to evaluate the treatment outcome. Kaplan-Meier method was adopted to carry out survival analysis and Log rank test was conducted to make a comparison.

Results

A total of 177 MBC patients were selected, in which 68 were in De novo stage IV. Thirty patients were human epidermal growth factor receptor 2 (HER2)-positive, 60 patients were triple-negative, and 87 patients were hormone receptor (HR)-positive and HER2-negative. In the whole population, patients with high baseline SUVmax, SUVmean, MTV, TLG or HI were associated with lower PFS (P=0.028, 0.005, 0.017, 0.026 and 0.035, respectively). Among the patients in De novo stage IV, those with high HI at baseline had significantly shorter PFS (P=0.001). In HR+/HER2- and HER2+ subgroups, only baseline HI showed the predictive value of PFS (P=0.023 and 0.049, respectively). In the triple-negative subgroup, high baseline SUVmax, MTV or TLG showed the predictive value of worse PFS (P=0.030, 0.011 and 0.023, respectively).

Conclusion

Pretreatment 18F-FDG-PET/CT parameters show the predictive value of PFS in MBC patients receiving first-line treatment. However, predictive PET/CT parameters might be different in patients with different molecular subtypes and De novo stage IV.

Prognostic Value of Dual-Time-Point 18F-Fluorodeoxyglucose PET/CT in Metastatic Breast Cancer: An Exploratory Study of Quantitative Measures

This study aimed to compare the prognostic value of quantitative measures of [¹⁸F]-fluorodeoxyglucose positron emission tomography with integrated computed tomography (FDG-PET/CT) for the response monitoring of patients with metastatic breast cancer (MBC). In this prospective study, 22 patients with biopsy-verified MBC diagnosed between 2011 and 2014 at Odense University Hospital (Denmark) were followed up until 2019. A dual-time-point FDG-PET/CT scan protocol (1 and 3 h) was applied at baseline, when MBC was diagnosed. Baseline characteristics and quantitative measures of maximum standardized uptake value (SUVmax), mean standardized uptake value (SUVmean), corrected SUVmean (cSUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG), and corrected TLG (cTLG) were collected. Survival time was analyzed using the Kaplan–Meier method and was regressed on MTV, TLG, and cTLG while adjusting for clinicopathological characteristics. Among the 22 patients included (median age: 59.5 years), 21 patients (95%) died within the follow-up period. Median survival time was 29.13 months (95% Confidence interval: 20.4–40 months). Multivariable Cox proportional hazards regression analyses of survival time showed no influence from the SUVmean, cSUVmean, or SUVmax, while increased values of MTV, TLG, and cTLG were significantly associated with slightly higher risk, with hazard ratios ranging between 1.0003 and 1.004 (p = 0.007 to p = 0.026). Changes from 1 to 3 h were insignificant for all PET measures in the regression model. In conclusion, MTV and TLG are potential prognostic markers for overall survival in MBC patients.

FDG-PET/CT Versus Contrast-Enhanced CT for Response Evaluation in Metastatic Breast Cancer: A Systematic Review

18F-fluorodeoxyglucose positron emission tomography with integrated computed tomography (FDG-PET/CT) and contrast-enhanced computed tomography (CT) can be used for response evaluation in metastatic breast cancer (MBC). In this study, we aimed to review literature comparing the PET Response Criteria in Solid Tumors (PERCIST) with Response Evaluation Criteria in Solid Tumors (RECIST) in patients with MBC. We made a systematic search in Embase, PubMed/Medline, and Cochrane Library using a modified PICO model. The population was MBC patients and the intervention was PERCIST or RECIST. Quality assessment was performed using the QUADAS-2 checklist. A total of 1975 articles were identified. After screening by title/abstract, 78 articles were selected for further analysis of which 2 duplicates and 33 abstracts/out of focus articles were excluded. The remaining 43 articles provided useful information, but only one met the inclusion and none of the exclusion criteria. This was a retrospective study of 65 patients with MBC showing one-year progression-free survival for responders versus non-responders to be 59% vs. 27% (p = 0.2) by RECIST compared to 64% vs. 0% (p = 0.0001) by PERCIST. This systematic literature review identified a lack of studies comparing the use of RECIST (with CE-CT) and PERCIST (with FDG-PET/CT) for response evaluation in metastatic breast cancer. The available sparse literature suggests that PERCIST might be more appropriate than RECIST for predicting prognosis in patients with MBC.

The Evolving Role of FDG-PET/CT in the Diagnosis, Staging, and Treatment of Breast Cancer

The applications of 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/X-ray computed tomography (PET/CT) in the management of patients with breast cancer have been extensively studied. According to these studies, PET/CT is not routinely performed for the diagnosis of primary breast cancer, although PET/CT in specific subtypes of breast cancer correlates with histopathologic features of the primary tumor. PET/CT can detect metastases to mediastinal, axial, and internal mammary nodes, but it cannot replace the sentinel node biopsy. In detection of distant metastases, this imaging tool may have a better accuracy in detecting lytic bone metastases compared to bone scintigraphy. Thus, PET/CT is recommended when advanced-stage disease is suspected, and conventional modalities are inconclusive. Also, PET/CT has a high sensitivity and specificity to detect loco-regional recurrence and is recommended in asymptomatic patients with rising tumor markers. Numerous studies support the future role of PET/CT in prediction of response to neoadjuvant chemotherapy (NAC). PET/CT has a higher diagnostic value for prognostic risk stratification in comparison with conventional modalities. With the continuing research on the treatment planning and evaluation of patients with breast cancer, the role of PET/CT can be further extended.

18F-FDG PET/CT for the early prediction of the response rate and survival of patients with recurrent or metastatic breast cancer

The present study aimed to explore the value of fludeoxyglucose F 18 positron emission tomography-computed tomography (PET/CT) for the early prediction of chemotherapy remission rates and survival in patients with recurrent and metastatic breast cancer. A total of 24 patients diagnosed with recurrent or metastatic breast cancer between 2009 and 2014 were enrolled. All patients underwent a PET/CT examination prior to (PET/CT1) and following (PET/CT2) chemotherapy. Differences of PET/CT1 maximal standardized uptake values (SUV_max), PET/CT2 SUV_max, ΔSUV_max and the ΔSUV_max% between objective remission (OR) and non-OR groups were measured. Survival differences between OR and non-OR groups and the overall survival (OS) between metabolic responsive and metabolic non-responsive groups were analyzed. In the present study, it was revealed that ΔSUV_max and ΔSUV_max% were significantly higher in the OR group compared with the non-OR group (P<0.001). Overall survival was significantly prolonged in the OR and metabolic responder groups compared with their respective control groups (P<0.001 and P<0.01, respectively). ΔSUV_max% were significantly positively associated with OS (r²=0.266; P<0.01). In conclusion, PET/CT may be valuable for the early prediction of the chemotherapy efficacy and survival of patients with recurrent or metastatic breast cancer.

Quantification of FDG-PET/CT with delayed imaging in patients with newly diagnosed recurrent breast cancer

Background

Several studies have shown the advantage of delayed-time-point imaging with 18F-FDG-PET/CT to distinguish malignant from benign uptake. This may be relevant in cancer diseases with low metabolism, such as breast cancer. We aimed at examining the change in SUV from 1 h (1h) to 3 h (3h) time-point imaging in local and distant lesions in patients with recurrent breast cancer. Furthermore, we investigated the effect of partial volume correction in the different types of metastases, using semi-automatic quantitative software (ROVER™).

Methods

One-hundred and two patients with suspected breast cancer recurrence underwent whole-body PET/CT scans 1h and 3h after FDG injection. Semi-quantitative standardised uptake values (SUVmax, SUVmean) and partial volume corrected SUVmean (cSUVmean), were estimated in malignant lesions, and as reference in healthy liver tissue. The change in quantitative measures from 1h to 3h was calculated, and SUVmean was compared to cSUVmean. Metastases were verified by biopsy.

Results

Of the 102 included patients, 41 had verified recurrent disease with in median 15 lesions (range 1-70) amounting to a total of 337 malignant lesions included in the analysis. SUVmax of malignant lesions increased from 6.4 ± 3.4 [0.9-19.7] (mean ± SD, min and max) at 1h to 8.1 ± 4.4 [0.7-29.7] at 3h. SUVmax in breast, lung, lymph node and bone lesions increased significantly (p < 0.0001) between 1h and 3h by on average 25, 40, 33, and 27%, respectively. A similar pattern was observed with (uncorrected) SUVmean. Partial volume correction increased SUVmean significantly, by 63 and 71% at 1h and 3h imaging, respectively. The highest impact was in breast lesions at 3h, where cSUVmean increased by 87% compared to SUVmean.

Conclusion

SUVs increased from 1h to 3h in malignant lesions, SUVs of distant recurrence were in general about twice as high as those of local recurrence. Partial volume correction caused significant increases in these values. However, it is questionable, if these relatively modest quantitative advances of 3h imaging are sufficient to warrant delayed imaging in this patient group.

Trial registration

ClinicalTrails.gov NCT01552655. Registered 28 February 2012, partly retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s12880-018-0254-8) contains supplementary material, which is available to authorized users.

Role of Fludeoxyglucose in Breast Cancer: Treatment Response

After an overview of the principles of fludeoxyglucose-PET/computed tomography (CT) in breast cancer, its advantages and limits to evaluate treatment response are discussed. The metabolic information is helpful for early assessment of the response to neoadjuvant chemotherapy and could be used to monitor treatment, especially in aggressive breast cancer subtypes. PET/CT is also a powerful method for early assessment of the treatment response in the metastatic setting. It allows evaluation of different sites of metastases in a single examination and detection of a heterogeneous response. However, to use PET/CT to assess responses, methodology for image acquisition and analysis needs standardization.

The prognostic value of positron emission tomography/computed tomography in pulmonary metastasectomy

Background

Although positron emission tomography/computed tomography (PET/CT) findings are prognostic in lung cancer patients, the prognostic value of PET/CT findings in patients with pulmonary metastases has neither been comprehensively investigated nor clarified. The aims of this retrospective study were to evaluate the value of PET/CT and identify novel prognostic indicators for pulmonary metastasectomy.

Methods

Between May 2004 and February 2017, 178 patients underwent PET/CT and resection of pulmonary metastases. After exclusion of patients who underwent biopsy only or duplicate cases, 142 patients were analyzed. Prognostic indicators, including PET/CT findings and outcomes were investigated.

Results

The median follow-up time was 42 months. The primary tumor site was colorectal in 76, kidney in 14, head and neck in 13, breast in 12, stomach in 8, urinary tract in 7, and other organs in 12 patients. The median maximal standardized uptake value (SUV_max) was 4.6. The optimal cut-off value, determined by receiver operating characteristic (ROC) analysis, identified the following cut-off values: disease-free interval (DFI) (12 months; SUV_max =4.5). Univariable analysis revealed that DFI ≤12 months, incomplete resection, and SUV_max ≥4.5 were significant for poor outcome. Multivariable analysis revealed incomplete resection and SUV_max ≥4.5 were significant for poor outcome. The 5-year survival rates of patients with SUV_max ≥4.5 and SUV_max <4.5 were 51.6% and 74.0%, respectively.

Conclusions

Analysis of patients undergoing pulmonary metastasectomy demonstrated that incomplete resection and an SUV_max ≥4.5 are significant prognostic indicators. PET/CT findings should be included in estimations of these patients' prognosis.

The usefulness of fluorodeoxyglucose-PET/CT for preoperative evaluation of ductal carcinoma in situ

Purpose

PET/CT is useful in preoperative evaluation of invasive breast cancer (IBC) to predict axillary metastasis and staging workup. The usefulness is unclear in cases of ductal carcinoma in situ (DCIS) diagnosed at biopsy before surgery, which sometimes is upgraded to IBC after definitive surgery. The aim of this study is to find out the usefulness of PET/CT on DCIS as a preoperative evaluation tool.

Methods

We investigated 102 patients preoperatively diagnosed with DCIS who subsequently underwent definitive surgery between 2010 and 2015. The uptake of ¹⁸F-fluorodeoxyglucose was graded by visual and semiquantitative methods. We analyzed the maximum standardized uptake value (SUVmax) of each patient with clinicopathologic variables. We determined optimal cutoff values for SUVmax by receiver operating characteristic curve analysis.

Results

Fifteen cases out of 102 cases (14.7%) were upgraded to IBC after surgery. The SUVmax was higher in patients upgraded to IBC (mean: 2.56 vs. 1.36) (P = 0.007). The SUVmax was significantly higher in patients who had symptoms, palpable masses, lesions over 2 cm in size and BI-RAD category 5. Both visual and semiquantitative analysis were significant predictors of IBC underestimation. SUVmax of 2.65 was the theoretical cutoff value in ROC curve analysis in predicting the underestimation of IBC. The underestimation rate was significantly higher in patients with SUVmax >2.65 (P < 0.001), over the moderate enhanced uptake on visual analysis (P < 0.001).

Conclusion

PET/CT can be used as a complementary evaluation tool to predict the underestimation of DCIS combined with the lesion size, palpable mass, symptomatic lesion, and BI-RAD category.

18F-FDG PET/CT is a prognostic biomarker in patients affected by bone metastases from breast cancer in comparison with 18F-NaF PET/CT

Aim: To compare 18F-FDG PET/CT and 18F-NaF PET/CT with respect to disease prognostication and outcome in patients affected by bone metastases from breast cancer (BC). Patients, methods: We retrospectively investigated 32 women with BC and documented bone metastases. Semi-quantitative parameters were applied to 18F-FDG PET/CT and 18F-Na PET/CT in order to evaluate disease extent and tumour metabolism. We used time-to-event analyses (Kaplan Meier and COX proportional hazard methods) to estimate progression-free (PFS) and overall survival (OS) in order to assess the independent prognostic value of 18F-FDG PET/CT and 18F-Na PET/CT. Results: The sensitivity of 18F-NaF PET/CT (100%) was higher (p < 0.05) than that of 18F-FDG PET/CT (72% and 72%). None of the 18F-FDG PET/CT-negative patients showed disease progression at the end of follow-up. After adjustment for age, Ki-67 levels, presence of visceral metastases, hormone therapy, duration of bone disease and response to first-line therapy, only 18F-FDG SUV mean [HR 15.7, 95% confidence interval (CI) 1.15-214.5] and 18F-FDG whole-body bone metabolic burden (WB-B-MB) (HR 16.9; 95%CI 1.87-152.2) were independently and significantly associated with OS. None of the 18F-NaF PET/CT parameters were associated with OS. None of the conventional clinical prognostic parameters remained significantly associated with OS after the inclusion of PET/ CT parameters in the model. Conclusion: 18F-FDG PET/CT is independently associated with OS in BC patients with bone metastases and its prognostic impact seems to be higher than conventional clinical and biological prognostic factors. Although 18F-NaF PET/CT has a higher diagnostic sensitivity than 18F-FDG PET/ CT, it is not independently associated with OS.

FDG PET/CT Assesses the Risk of Femoral Pathological Fractures in Patients With Metastatic Breast Cancer

PURPOSE

Assessment of pathological fracture risk is critical to optimize the use of prophylactic orthopedic fixation to prevent pathological fractures. Better prediction of pathological fracture risk is needed. We evaluated if quantitative measures of FDG avidity can assess femoral pathological fracture risk in patients with metastatic breast cancer (MBC).

PATIENTS AND METHODS

A Health Insurance Portability and Accountability Act-compliant retrospective case-control study was performed under institutional review board waiver. Patients with MBC who received an FDG PET/CT from January 2008 to December 2014 and had pathological fracture of the proximal femur within 3 months of PET/CT were selected as cases. Patients with MBC who had an FDG PET/CT in 2013 were sequentially screened in reverse chronological order to identify patients with proximal femoral metastases on PET/CT but no subsequent pathological fracture to serve as a control group. The prespecified goal was to have twice the number of controls as cases. Target lesions in the proximal femur, from femoral head to 5 cm below the lesser trochanter, were analyzed on FDG PET/CT for SUVmax, SUVmean, metabolic tumor volume, and total lesion glycolysis. Wilcoxon rank sum test was used to compare continuous variables in cases and controls. A nonparametric receiver operating characteristic analysis was performed to assess the ability of quantitative FDG measurements to differentiate between cases and controls.

RESULTS

In 27 cases with pathological fracture and 55 controls without pathological fracture, all 4 quantitative measures of FDG avidity were statistically different between cases and controls (P < 0.001). A total lesion glycolysis of 81 could differentiate between fracture and nonfracture patients with accuracy, sensitivity, and specificity of 0.83, 0.85, and 0.80, respectively.

CONCLUSIONS

Quantitative measures of FDG avidity may help identify breast cancer patients at high risk of subsequent pathological fracture of the proximal femur.

Relationship between primary tumour 18F-FDG uptake and immunohistochemical and clinical prognostic parameters in breast carcinoma

OBJECTIVE

The objective of this study was to investigate the relationship between level of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) accumulation in primary breast tumour assessed by positron emission tomography/computed tomography (PET/CT) and histopathological and clinical prognostic factors.

MATERIAL AND METHODS

A retrospective analysis was performed using the medical records of 58 female patients (age range: 31-86 years, mean age: 56) with biopsy of proven breast carcinoma, and who had undergone ¹⁸F-FDG PET/CT examination before chemotherapy/surgery. The ¹⁸F-FDG uptake of breast tumours was calculated as tumour to background ratio (TBR), which was compared with histopathological and clinical prognostic parameters.

RESULTS

The histology of the breast tumour in the 58 patients was ductal type in 52 (90%), lobular in 4 (7%), and mucinous in 2 (3%). Tumour size was ≤ 2cm in 31 (53%) patients, and>2cm in 27 (47%). The levels of TBRs were not significantly different between the patients groups with tumours of 2cm or less and greater than 2cm (P=0.131). No significant difference between levels of TBR was observed neither with regards to axillary lymph node involvement (P=0.065) nor in terms of distant metastases (p=0.123). No statistically significant difference was found in levels of TBRs between patients with c-erbB-2 receptor positive and negative ones (P=0.107). Progesterone receptor (PR) expression was observed in 33 patients (57%), and 25 patients (43%) were PR negative. As regards progesterone receptor status, a statistically significant difference was observed in mean TBR levels between patients with and without progesterone receptor expression (P=0.020). Oestrogen receptor expression was positive in 41 (71%) patients, and negative in 17 (29%) patients. The difference in the levels of TBRs between patients with and without oestrogen receptor expression was at the level of significancy (P=0.050).

CONCLUSIONS

It is concluded that ¹⁸F-FDG uptake correlates with progesterone negativity of the tumour. However, a significant association with clinical prognostic parameters and level of ¹⁸F-FDG uptake levels could not be demonstrated.

Molecular Imaging and Precision Medicine in Breast Cancer

Precision medicine, basing treatment approaches on patient traits and specific molecular features of disease processes, has an important role in the management of patients with breast cancer as targeted therapies continue to improve. PET imaging offers noninvasive information that is complementary to traditional tissue biomarkers, including information about tumor burden, tumor metabolism, receptor status, and proliferation. Several PET agents that image breast cancer receptors can visually demonstrate the extent and heterogeneity of receptor-positive disease and help predict which tumors are likely to respond to targeted treatments. This review presents applications of PET imaging in the targeted treatment of breast cancer.

¹⁸F-FDG PET/CT for Monitoring of Treatment Response in Breast Cancer

Changes in tumor metabolic activity have been shown to be an early indicator of treatment effectiveness for breast cancer, mainly in the neoadjuvant setting. The histopathologic response at the completion of chemotherapy has been used as the reference standard for assessment of the accuracy of (18)F-FDG PET in predicting a response during systemic treatment. Although a pathologic complete response (pCR) remains an important positive prognostic factor for an individual patient, a recent metaanalysis could validate pCR as a surrogate marker for patient outcomes only in aggressive breast cancer subtypes. For establishment of the clinical application of metabolic treatment response studies, larger series of specific breast cancer subtypes-including hormone receptor-positive, human epidermal growth factor receptor 2-positive, and triple-negative breast cancers-are necessary. In addition, thresholds for relative changes in (18)F-FDG uptake to distinguish between responding and nonresponding tumors need to be validated for different systemic treatment approaches, with progression-free survival and overall survival as references. A PET-based treatment stratification is applicable clinically only if valid alternative therapies are available. Of note, patients who do not achieve a pCR might still benefit from neoadjuvant therapy enabling breast-conserving surgery. In the metastatic setting, residual tumor metabolic activity after the initiation of systemic therapy is an indicator of active disease, whereas a complete resolution of metabolic activity is predictive of a successful treatment response.

Application of positron emission tomography (PET/CT) in diagnosis of breast cancer. Part I. Diagnosis of breast cancer prior to treatment

Positron emission tomography with computed tomography (PET/CT) is gaining popularity as a method for overall staging assessment of breast cancer. Currently, it is not a part of the routine workup before the beginning of treatment, because of insufficient sensitivity for the detection of small tumors (due to its limited spatial resolution), the heterogeneity of radiotracer uptake by the primary tumor, and unsatisfactory sensitivity in detection of lymph node metastases (particularly when they are small). Nevertheless, it should be considered when there is a high risk of metastases, because then initial PET/CT examination allows for accurate staging and may change the treatment algorithm in up to almost 50% of stage III patients, due to detection of distant and lymph node metastases throughout the whole body. Despite the discussed limitations of PET/CT, there is ongoing research concerning the recommendations for the examination prior to treatment. For a particular group of patients with high risk of metastases, PET/CT may be expected to become a part of the routine workup as the most appropriate staging method.

The clinical significance of standardized uptake value in breast cancer measured using 18F-fluorodeoxyglucose positron emission tomography/computed tomography

OBJECTIVE

The objective of this study was to investigate the clinical and biological significance of F-fluorodeoxyglucose (F-FDG) uptake levels in breast cancer patients.

PATIENTS AND METHODS

F-FDG PET/computed tomography was performed in 206 women with breast cancer, and the standardized uptake value (SUV) in breast cancer was analyzed to test associations with prognostic parameters.

RESULTS

PET/computed tomography sensitivity for primary tumor detection was 90.4% (206/228) and sensitivity and specificity for metastatic axillary lymph node were 72.6% (45/62) and 84.7% (122/144), respectively. A high SUV was significantly associated with large tumor size (>2 cm, P<0.001), positive axillary lymph node metastasis (P<0.001), distant metastasis (P=0.016), higher tumor node metastasis stage (P<0.001), higher histologic grade (P<0.001), higher nuclear grade (P<0.001), estrogen receptor negativity (P<0.001), progesterone receptor negativity (P<0.001), triple negativity (P=0.006), B-cell lymphoma/leukemia-2 negativity (P=0.031), cytokeratin 5/6 positivity (P=0.001), epidermal growth factor receptor positivity (P=0.005), and Ki67 positivity (P=0.003). Multivariate analysis showed that tumor size (>2 cm, P=0.001), positive axillary lymph node metastasis (P=0.028), and estrogen receptor negativity (P<0.001) were significantly associated with the SUV.

CONCLUSION

High levels of F-FDG uptake in primary breast cancer were correlated with poor prognostic factors and aggressive biologic markers such as triple negativity, markers of basal-type cancer, and Ki67. The SUV might be predictive of biologic markers and assist therapeutic decision making.

The Impact That Number of Analyzed Metastatic Breast Cancer Lesions Has on Response Assessment by 18F-FDG PET/CT Using PERCIST

The PET Response Criteria in Solid Tumors (PERCIST) are not specific regarding the number of lesions that should be analyzed per patient. This study evaluated how the number of analyzed lesions affects response assessment in metastatic breast cancer.

METHODS

In 60 patients, response was assessed by the change in SUVpeak, normalized to lean body mass, of the most (18)F-FDG-avid lesion (PERCIST 1) and by the change in the sum of normalized SUVpeak for up to 5 lesions (PERCIST 5). The correlation between response by PERCIST and progression-free and disease-specific survival was evaluated.

RESULTS

In responders and nonresponders, the respective progression-free survival at 2 y was 37.26% and 6.43% for PERCIST 1 (P < 0.0001) and 33.65% and 7.14% for PERCIST 5 (P < 0.0001) and the respective disease-specific survival at 4 y was 58.96% and 25.44% for PERCIST 1 (P < 0.012) and 59.12% vs 20.01% for PERCIST 5 (P < 0.002).

CONCLUSION

The number of analyzed lesions does not appear to have a major impact on the prognostic value of response assessment with (18)F-FDG PET/CT in metastatic breast cancer.

Incidence of Internal Mammary Lymph Nodes with Silicone Breast Implants at MR Imaging after Oncoplastic Surgery

PURPOSE

To assess the incidence of benign and malignant internal mammary lymph nodes (IMLNs) at magnetic resonance (MR) imaging among women with a history of treated breast cancer and silicone implant reconstruction.

MATERIALS AND METHODS

The institutional review board approved this HIPAA-compliant retrospective study and waived informed consent. Women were identified who (a) had breast cancer, (b) underwent silicone implant oncoplastic surgery, and (c) underwent postoperative implant-protocol MR imaging with or without positron emission tomography (PET)/computed tomography (CT) between 2000 and 2013. The largest IMLNs were measured. A benign IMLN was pathologically proven or defined as showing 1 year of imaging stability and/or no clinical evidence of disease. Malignant IMLNs were pathologically proven. Incidence of IMLN and positive predictive value (PPV) were calculated on a per-patient level by using proportions and exact 95% confidence intervals (CIs). The Wilcoxon rank sum test was used to assess the difference in axis size.

RESULTS

In total, 923 women with breast cancer and silicone implants were included (median age, 46 years; range, 22-89 years). The median time between reconstructive surgery and first MR imaging examination was 49 months (range, 5-513 months). Of the 923 women, 347 (37.6%) had IMLNs at MR imaging. Median short- and long-axis measurements were 0.40 cm (range, 0.20-1.70 cm) and 0.70 cm (range, 0.30-1.90 cm), respectively. Two hundred seven of 923 patients (22.4%) had adequate follow-up; only one of the 207 IMLNs was malignant, with a PPV of 0.005 (95% CI: 0.000, 0.027). Fifty-eight of 923 patients (6.3%) had undergone PET/CT; of these, 39 (67.2%) had IMLN at MR imaging. Twelve of the 58 patients (20.7%) with adequate follow-up had fluorine 18 fluorodeoxyglucose-avid IMLN, with a median standardized uptake value of 2.30 (range, 1.20-6.10). Only one of the 12 of the fluorodeoxyglucose-avid IMLNs was malignant, with a PPV of 0.083 (95% CI: 0.002, 0.385).

CONCLUSION

IMLNs identified at implant-protocol breast MR imaging after oncoplastic surgery for breast cancer are overwhelmingly more likely to be benign than malignant. Imaging follow-up instead of immediate metastatic work-up may be warranted.

Appearance of untreated bone metastases from breast cancer on FDG PET/CT: importance of histologic subtype

PURPOSE

To determine if the histology of a breast malignancy influences the appearance of untreated osseous metastases on FDG PET/CT.

METHODS

This retrospective study was performed under IRB waiver. Our Hospital Information System was screened for breast cancer patients who presented with osseous metastases, who underwent FDG PET/CT prior to systemic therapy or radiotherapy from 2009 to 2012. Patients with invasive ductal carcinoma (IDC), invasive lobular carcinoma (ILC), or mixed ductal/lobular (MDL) histology were included. Patients with a history of other malignancies were excluded. PET/CT was evaluated, blinded to histology, to classify osseous metastases on a per-patient basis as sclerotic, lytic, mixed lytic/sclerotic, or occult on CT, and to record SUVmax for osseous metastases on PET.

RESULTS

Following screening, 95 patients who met the inclusion criteria (74 IDC, 13 ILC, and 8 MDL) were included. ILC osseous metastases were more commonly sclerotic and demonstrated lower SUVmax than IDC metastases. In all IDC and MDL patients with osseous metastases, at least one was FDG-avid. For ILC, all patients with lytic or mixed osseous metastases demonstrated at least one FDG-avid metastasis; however, in only three of seven patients were sclerotic osseous metastases apparent on FDG PET.

CONCLUSION

The histologic subtype of breast cancer affects the appearance of untreated osseous metastases on FDG PET/CT. In particular, non-FDG-avid sclerotic osseous metastases were more common in patients with ILC than in patients with IDC. Breast cancer histology should be considered when interpreting non-FDG-avid sclerotic osseous lesions on PET/CT, which may be more suspicious for metastases (rather than benign lesions) in patients with ILC.

Positron Emission Tomography in Breast Cancer

Gradually, FDG-PET/CT has been strengthening within the diagnostic algorithms of oncological diseases. In many of these, PET/CT has shown to be useful at different stages of the disease: diagnosis, staging or re-staging, treatment response assessment, and recurrence. Some of the advantages of this imaging modality versus CT, MRI, bone scan, mammography, or ultrasound, are based on its great diagnostic capacity since, according to the radiopharmaceutical used, it reflects metabolic changes that often occur before morphological changes and therefore allows us to stage at diagnosis. Moreover, another advantage of this technique is that it allows us to evaluate the whole body so it can be very useful for the detection of distant disease. With regard to breast cancer, FDG-PET/CT has proven to be important when recurrence is suspected or in the evaluation of treatment response. The technological advancement of PET equipment through the development of new detectors and equipment designed specifically for breast imaging, and the development of more specific radiopharmaceuticals for the study of the different biological processes of breast cancer, will allow progress not only in making the diagnosis of the disease at an early stage but also in enabling personalized therapy for patients with breast cancer.

Whole-body total lesion glycolysis measured on fluorodeoxyglucose positron emission tomography/computed tomography as a prognostic variable in metastatic breast cancer

Background

In this retrospective study, the authors evaluated the prognostic value of whole-body total lesion glycolysis (WTLG) on FDG/PET images in metastatic breast cancer (MBC) patients.

Methods

We retrospectively evaluated 54 MBC patients who were diagnosed as having one or more metastatic lesions between June 2005 and March 2013. Twenty-four patients were diagnosed at the initial presentation (group A) and 30 patients were diagnosed for the first time at some point after a surgery (group B). Patients were excluded if they had received chemotherapy within 30 days before PET/CT. SUV_max and total TLG were calculated for all lesions in each patient and the highest SUV_max and the whole-body TLG (WTLG) values were used as independent variables for the analyses. Mean ages and the proportions of histopathological subtypes were compared between two groups using Mann–Whitney U test and Fisher’s exact test, respectively. The prognostic significance of PET parameters was assessed using Cox proportional hazards regression analysis.

Results

For groups A and B, the median follow-up period was 26 months (range, 3–58 months) and 40.5 months (range, 3–69 months), and the median age was 61 years (range, 42–81 years) and 59 years (range, 24–74 years), respectively. There were no significant differences between two groups in age (p = 0.294) or histopathological subtype (p = 0.384). In the univariate analyses, WTLG was found to be significantly associated with overall survival (OS) for patients of group A (p = 0.012). In the multivariate analysis, WTLG was also significantly associated with OS (p = 0.015). Only hormonal receptor level was a significant indicator of longer OS in patients with recurrent MBC (group B).

Conclusions

This study demonstrated that WTLG on PET/CT is an independent prognostic factor for survival in breast cancer patients with metastases at the initial presentation.

Role of FDG-PET/CT in prediction of underestimation of invasive breast cancer in cases of ductal carcinoma in situ diagnosed at needle biopsy

BACKGROUND

The aim of this study was to evaluate the significance of FDG-PET/CT for predicting the underestimation of invasive breast cancer in cases of DCIS at needle biopsy.

PATIENTS AND METHODS

Of 83 consecutive cases with diagnoses of DCIS at primary needle biopsy who underwent curative surgery between 2010 and 2013, the association between the SUVmax on FDG-PET/CT before excision and the underestimation of invasive breast cancer was examined.

RESULTS

There were 29 (34.9%) cases diagnosed to have invasive breast cancer at excision. Receiver operating characteristics curve analysis showed the cutoff value of the SUVmax to predict underestimation of invasive breast cancer was 1.6. The rates of underestimation were 61.5% for patients with a tumor of SUVmax > 1.6 and 11.4% for patients with a tumor of SUVmax ≤ 1.6 (P < .001). A high value of SUVmax was significantly associated with symptomatic presentation (P < .001), palpability (P < .001), mass formation (P = .013), high Breast Imaging Reporting and Data System category (P = .011), and core needle biopsy (P = .007). In multivariate analysis, high SUVmax was only a significant predictive factor of underestimation of invasive breast cancer (hazard ratio, 11.7; 95% confidence interval, 3.70-37.0; P < .001).

CONCLUSION

SUVmax on FDG-PET/CT is useful for predicting the underestimation of invasive breast cancer in cases of DCIS at needle biopsy.

Circulating Tumor Cells in Metastatic Breast Cancer: A Prognostic and Predictive Marker

The role of circulating tumor cells (CTCs) as a marker for disease progression in metastatic cancer is controversial. The current review will serve to summarize the evidence on CTCs as a marker of disease progression in patients with metastatic breast cancer. The immunohistochemistry(IHC)-based CellSearch^® is the only FDA-approved isolation technique for quantifying CTCs in patients with metastatic breast cancer. We searched PubMed and Web of Knowledge for clinical studies that assessed the prognostic and predictive value of CTCs using IHC-based isolation. The patient outcomes reported include median and Cox-proportional hazard ratios for overall-survival (OS) and progression-free-survival (PFS). All studies reported shorter OS for CTC-positive patients versus CTC-negative. A subset of the selected trials reported significant lower median PFS for CTC-positive patients. The reported trials support the utility of CTC enumeration for patient prognosis. But further studies are required to determine the utility of CTC enumeration for guiding patient therapy. There are three clinical trials ongoing to test this hypothesis. These studies, and others, will further establish the role of CTCs in clinical practice.

Prognostic significance of SUVmax and serum carbohydrate antigen 19-9 in pancreatic cancer

AIM: To investigate the prognostic significance of pretreatment standardized maximum uptake value (SUVmax) and serum carbohydrate antigen (CA)19-9 in pancreatic cancer.

METHODS: From January 2007 to October 2011, 80 consecutive patients with pancreatic cancer who received positron emission/computed tomography before any treatment were enrolled in this study. The pretreatment SUVmax and CA19-9 level of the primary pancreatic tumor were obtained and compared with clinicopathological and prognostic factors. Student’s t test for unpaired data was used to analyze the differences between two groups. Univariate analysis and Cox proportional hazards regression were used to examine the independent effects of each significant variable. Survival was analyzed by the Kaplan-Meier method.

RESULTS: There was a significant correlation between both the SUVmax and serum CA19-9 of pancreatic cancer and R0 surgical resection (P = 0.043 and P = 0.007). Lymph node metastasis was associated with SUVmax (P = 0.017), but not serum CA19-9 (P = 0.172). On the contrary, the tumor stage was significantly related to serum CA19-9 (P = 0.035), but not SUVmax (P = 0.110). The univariate analysis showed that survival time was significantly related to tumor stage (P < 0.001), lymph node metastasis (P = 0.043), R0 surgical resection (P < 0.001), serum CA19-9 (P = 0.001), SUVmax (P < 0.001) and SUVmax plus CA19-9 (P = 0.002). Multivariate analysis clearly showed that only tumor stage (hazard ratio = 0.452; P = 0.020) was an independent prognostic factor for overall survival in pancreatic cancer. Higher SUVmax or CA19-9 showed worse prognosis. We found that high serum CA19-9 plus SUVmax was the most significant variable.

CONCLUSION: Higher pretreatment SUVmax and serum CA19-9 indicates poor prognosis. SUVmax plus serum CA19-9 is the most significant variable in predicting survival.

A phase IIa, nonrandomized study of radium-223 dichloride in advanced breast cancer patients with bone-dominant disease

Radium-223 dichloride (radium-223) mimics calcium and emits high-energy, short-range alpha-particles resulting in an antitumor effect on bone metastases. This open-label, phase IIa nonrandomized study investigated safety and short-term efficacy of radium-223 in breast cancer patients with bone-dominant disease. Twenty-three advanced breast cancer patients with progressive bone-dominant disease, and no longer candidates for further endocrine therapy, were to receive radium-223 (50 kBq/kg IV) every 4 weeks for 4 cycles. The coprimary end points were change in urinary N-telopeptide of type 1 (uNTX-1) and serum bone alkaline phosphatase (bALP) after 16 weeks of treatment. Exploratory end points included sequential ¹⁸F-fluorodeoxyglucose positron emission tomography and computed tomography (FDG PET/CT) to assess metabolic changes in osteoblastic bone metastases. Safety data were collected for all patients. Radium-223 significantly reduced uNTX-1 and bALP from baseline to end of treatment. Median uNTX-1 change was −10.1 nmol bone collagen equivalents/mmol creatinine (−32.8 %; P = 0.0124); median bALP change was −16.7 ng/mL (−42.0 %; P = 0.0045). Twenty of twenty-three patients had FDG PET/CT identifying 155 hypermetabolic osteoblastic bone lesions at baseline: 50 lesions showed metabolic decrease (≥25 % reduction of maximum standardized uptake value from baseline) after 2 radium-223 injections [32.3 % metabolic response rate (mRR) at week 9], persisting after the treatment period (41.5 % mRR at week 17). Radium-223 was safe and well tolerated. Radium-223 targets areas of increased bone metabolism and shows biological activity in advanced breast cancer patients with bone-dominant disease.

Diagnostic accuracy of (18) F-methylcholine positron emission tomography/computed tomography for intra- and extrahepatic hepatocellular carcinoma

Diagnosis of hepatocellular carcinoma (HCC) primarily involves imaging. The aim of this study was to assess the accuracy of (18) F-fluorocholine ((18) F-FCH) positron emission tomography (PET) for detection of HCC and evaluation of extent of disease. Patients with HCC >1 cm were included between 2009 and July 2011, and follow-up closed in February 2013. Diagnosis was based on American Association for the Study of Liver Diseases criteria, and all patients underwent (18) F-FCH PET/computed tomography (CT) at baseline before treatment, 6 underwent a second PET/CT posttreatment, and 1 a third during follow-up. Whole-body PET and low-dose CT imaging were performed 15 minutes after (18) F-FCH injection. Evaluation of imaging was done with standardized uptake value (SUV) ratios: SUV maximum of the lesion divided by the SUV mean of surrounding tissue. Statistical analyses included descriptive analyses, receiver operating characteristic curve, McNemar's test, and Kaplan-Meier's test at 5% level of significance. Twenty-nine patients revealed 53 intrahepatic lesions. In 48 of 53 lesions, (18) F-FCH PET was positive (SUVratio , 1.95 ± 0.66; sensitivity, 88%; specificity, 100%). PET/CT showed uptake in 18 extrahepatic lesions and no uptake in 3 lesions affirmed non-HCC lesions; all lesions were confirmed with additional investigation (accuracy, 100%). In 17 of 29 patients, additional lesions were found on PET/CT imaging, with implications for treatment in 15 patients. Posttreatment PET/CT showed identical results, compared with standard treatment evaluation.

CONCLUSION

This study shows additional value of (18) F-FCH PET/CT for patients with HCC. (18) F-FCH PET/CT has implications for staging, management, and treatment evaluation because of accurate assessment of extrahepatic disease.

Role of positron emission tomography/computed tomography in breast cancer

Although positron emission tomography (PET) imaging may not be used in the diagnosis of breast cancer, the use of PET/computed tomography is imperative in all aspects of breast cancer staging, treatment, and follow-up. PET will continue to be relevant in personalized medicine because accurate tumor status will be even more critical during and after the transition from a generic metabolic agent to receptor imaging. Positron emission mammography is an imaging proposition that may have benefits in lower doses, but its use is limited without new radiopharmaceuticals.

Thymic metastasis of breast cancer 22 years after surgery: a case report

We report a rare case of thymic metastasis of breast cancer. A 68-year-old woman, who had undergone surgery for cancer in her right breast and had been free of recurrence for 22 years, was noted to have an abnormal shadow on a chest X-ray at a regular medical checkup. Further workup, including chest CT, revealed a 22 × 18-mm mass in the anterior mediastinum. Fluorine-18-fluorodeoxyglucose-PET showed increased fluorine-18-fluorodeoxyglucose uptake that was highly suggestive of thymoma. Thoracoscopic thymothymectomy was performed. The tumor had invaded the pericardium, which was also resected. A small nodule was found in the right lung, and it was also resected. The intraoperative frozen-section diagnosis was breast cancer metastasis to the thymus and lung. The pathological diagnosis was luminal A solid tubular carcinoma (strongly estrogen receptor and progesterone receptor positive, HER2 negative) with an MIB-1 index of less than 5%. After surgery, the patient was treated with an aromatase inhibitor. As of August 2013, she has been free of recurrence for more than 36 months. It is extremely rare for breast cancer to metastasize to the thymus more than 20 years after surgery.

Role of maximum standardized uptake value in fluorodeoxyglucose positron emission tomography/computed tomography predicts malignancy grade and prognosis of operable breast cancer: a multi-institute study

The malignant biological behavior of breast cancer remains obscure on diagnostic images, although understanding the grade of such malignancy is important for selecting appropriate treatment. Therefore, malignancy grades in operable breast cancer were evaluated using positron emission tomography/computed tomography (PET/CT) in a multicenter setting. We prospectively examined the features and prognosis of 344 patients (mean age ± SD: 58.0 ± 12.5 years) with clinical stages I–III breast cancer, who underwent surgical intervention without induction therapy between January 2006 and December 2011. Maximum standardized uptake values (maxSUV) obtained from whole-body fluorodeoxyglucose-PET/CT immediately before surgery were assessed to predict the malignant aggressiveness of tumors including the recurrence-free survival of the patients. Variations in maxSUV among institutions, which are limitations of PET assessments in multicenter studies, were adjusted using a phantom study. The median follow up period was 52 months. The patients were divided into groups according to cut-off maxSUV (≤3.0 vs. >3.0) values established from receiver operating characteristic analysis of recurrence (area under the curve = 0.713). A higher maxSUV was significantly associated with a higher T-factor (p < 0.0001), N-factor (p = 0.0049), nuclear grade (p < 0.0001), negative for estrogen (p = 0.0309), and progesterone receptors (p = 0.0063), positive for human epidermal growth factor receptor 2 (p = 0.0012), lymph node metastasis (p = 0.0128), and vascular invasion (p = 0.0110). Multivariate analysis using Cox proportional hazard regression model revealed high maxSUV and negative estrogen receptor status as significantly prognostic factors (p = 0.033 and p = 0.004, respectively). This study demonstrated that maxSUV on PET/CT as well as estrogen receptor status is useful to predict malignancy grades and the prognosis of patients with breast cancer.

Prognostic value of quantitative fluorodeoxyglucose measurements in newly diagnosed metastatic breast cancer

The aim of this study was to determine the prognostic value of quantitative fluorodeoxyglucose (FDG) measurements (maximum standardized uptake value [SUVmax ], metabolic tumor volume [MTV], and total lesion glycolysis [TLG]) in patients with newly diagnosed metastatic breast cancer (MBC). An IRB-approved retrospective review was performed of patients who underwent FDG positron emission tomography (PET)/computed tomography (CT) from 1/02 to 12/08 within 60 days of diagnosis MBC. Patients with FDG-avid lesions without receiving chemotherapy in the prior 30 days were included. Target lesions in bone, lymph node (LN), liver, and lung were analyzed for SUVmax , MTV, and TLG. Medical records were reviewed for patient characteristics and overall survival (OS). Cox regression was used to test associations between quantitative FDG measurements and OS. A total of 253 patients were identified with disease in bone (n = 150), LN (n = 162), liver (n = 48), and lung (n = 66) at the time of metastatic diagnosis. Higher SUVmax tertile was associated with worse OS in bone metastases (highest vs. lowest tertile hazard ratio [HR] = 3.1, P < 0.01), but not in LN, liver or lung (all P > 0.1). Higher MTV tertile was associated with worse OS in LN (HR = 2.4, P < 0.01) and liver (HR = 3.0, P = 0.02) metastases, but not in bone (P = 0.22) or lung (P = 0.14). Higher TLG tertile was associated with worse OS in bone (HR = 2.2, P = 0.02), LN (HR = 2.3, P < 0.01), and liver (HR = 4.9, P < 0.01) metastases, but not in lung (P = 0.19). We conclude measures of FDG avidity are prognostic biomarkers in newly diagnosed MBC. SUVmax and TLG were both predictors of survival in breast cancer patients with bone metastases. TLG may be a more informative biomarker of OS than SUVmax for patients with LN and liver metastases.

What predicts the risk of recurrent lung metastases?

PURPOSE

The purpose of this study was to determine what factors predict recurrent lung metastatic disease in pediatric oncology patients.

METHODS

A retrospective review of 50 patients who underwent resection of lung nodules that were positive for metastatic disease from 1998 to 2011 was performed. Risk factors for recurrence were determined by multi-variable logistic regression models.

RESULTS

Fifty pediatric oncology patients underwent resection of discrete lung nodules seen on CT scans during work-up for metastasis or for routine surveillance. Out of this patient cohort, 23 (46%) patients had recurrent disease. The only significant factors that influenced risk of recurrence were original PET positive study (p<0.05) and patients with osteosarcoma (p<0.002). The type of surgical procedure, margins of original resection, race, age, gender, size, or the number of original nodules was not found to be significant.

CONCLUSION

Patients with osteosarcoma and PET positive disease at original presentation appear to be at the highest risk of recurrent pulmonary metastatic disease. New pulmonary lesions in these patients should undergo biopsy to confirm metastatic disease.

The maximum standardized uptake value of 18 F-FDG PET scan to determine prognosis of hormone-receptor positive metastatic breast cancer

Background

Whether PET scan maximum standard uptake value (SUVmax) could differentiate luminal A from luminal B and help predict the survival of metastatic breast cancer (MBC) patients with luminal subtype is still unknown and need to be investigated.

Methods

305 MBC patients with luminal subtypes were screened with PET/CT. Eligible patients were prospectively followed up.

Results

In total, 134 patients were eligible for this study. SUVmax was significantly related to the number of metastatic sites and presence of visceral metastasis on univariate analysis. SUVmax could not effectively differentiate patients with luminal A from luminal B subtype. Although luminal subtype at diagnosis could predict the relapse-free interval, it could not predict progression-free survival (PFS) or overall survival (OS) after developing relapse. In contrast, SUVmax was predictive of both PFS and OS and this effect was maintained in multivariate COX regression model.

Conclusions

SUVmax of MBC did not correlate with molecular subtypes of primary tumor. While molecular subtype may be a valuable prognostic factor at primary diagnosis of breast cancer, the SUVmax, rather than molecular subtype, does have a potential to predict independently in multivariate analysis for the PFS and OS in patients with metastatic disease of luminal subtype.

Advances in oncologic imaging: update on 5 common cancers

Imaging has become a pivotal component throughout a patient's encounter with cancer, from initial disease detection and characterization through treatment response assessment and posttreatment follow-up. Recent progress in imaging technology has presented new opportunities for improving clinical care. This article provides updates on the latest approaches to imaging of 5 common cancers: breast, lung, prostate, and colorectal cancers, and lymphoma.

The role of 18F-FDG PET/CT metabolic tumour volume in predicting survival in patients with metastatic nasopharyngeal carcinoma

OBJECTIVES

To investigate the role of PET-derived imaging markers in predicting metastatic nasopharyngeal carcinoma (NPC) outcomes.

MATERIALS AND METHODS

A total of 56 patients with metastatic NPC were enrolled. Before treatment, all of the participants underwent (18)F-FDG PET/CT. The following (18)F-FDG PET parameters were assessed: standardised uptake value, metabolic tumour volume (MTV), and total lesion glycolysis. Multivariate Cox proportional hazards models were used to identify the independent predictors of survival.

RESULTS

The multivariate analysis showed that performance status>1 (P=0.007), Epstein-Barr virus (EBV) DNA titre>5000 copies/mL (P=0.001), and MTV>110 mL (P=0.013) were independent risk factors for progression-free survival (PFS). Male sex (P=0.004), performance status>1 (P<0.0001), EBV DNA level>5000 copies/mL (P<0.0001), and MTV>110 mL (P=0.003) independently predicted overall survival (OS). The 2-year PFS and OS rates of the patients with MTV≤110 mL were 23.2% and 43%, respectively, compared with 0% and 9.1%, respectively, for those with MTV>110 mL. Combining the MTV with the EBV DNA titre allowed further survival stratification by dividing the patients into three groups with distinct PFS (2-year rates=30.8%, 7.1%, and 0%, P<0.0001) and OS (2-year rates=68.4%, 40%, and 0%, P<0.0001) rates.

CONCLUSION

The MTV appears to be an independent risk factor in metastatic NPC patients. This factor is complementary to the EBV DNA titre for predicting survival in metastatic NPC.

Diagnostic and prognostic correlates of preoperative FDG PET for breast cancer

PURPOSE

To explore the preoperative utility of FDG PET for the diagnosis and prognosis in a retrospective breast cancer case series.

METHODS

In this retrospective study, 104 patients who had undergone a preoperative FDG PET scan for primary breast cancer at the UZ Brussel during the period 2002-2008 were identified. Selection criteria were: histological confirmation, FDG PET performed prior to therapy, and breast surgery integrated into the primary therapy plan. Patterns of increased metabolism were recorded according to the involved locations: breast, ipsilateral axillary region, internal mammary chain, or distant organs. The end-point for the survival analysis using Cox proportional hazards was disease-free survival. The contribution of prognostic factors was evaluated using the Akaike information criterion and the Nagelkerke index.

RESULTS

PET positivity was associated with age, gender, tumour location, tumour size >2 cm, lymphovascular invasion, oestrogen and progesterone receptor status. Among 63 patients with a negative axillary PET status, 56 (88.9 %) had three or fewer involved nodes, whereas among 41 patients with a positive axillary PET status, 25 (61.0 %) had more than three positive nodes (P < 0.0001). In the survival analysis of preoperative characteristics, PET axillary node positivity was the foremost statistically significant factor associated with decreased disease-free survival (hazard ratio 2.81, 95% CI 1.17-6.74).

CONCLUSION

Preoperative PET axillary node positivity identified patients with a higher burden of nodal involvement, which might be important for treatment decisions in breast cancer patients.