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Covington MF, O'Brien SR, Lawhn-Heath C, Pantel AR, Ulaner GA, Linden HM, Dehdashti F. Fluorine-18-Labeled Fluoroestradiol PET/CT: Current Status, Gaps in Knowledge, and Controversies-AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2023. [PMID: 38117098 DOI: 10.2214/ajr.23.30330] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PET/CT using 16α-[18F]-fluoro-17β-estradiol (FES) noninvasively images tissues expressing estrogen receptors (ERs). FES has undergone extensive clinicopathologic validation for ER+ breast cancer and received FDA approval in 2020 for clinical use as an adjunct to biopsy in patients with recurrent or metastatic ER+ breast cancer. Clinical use of FES PET/CT is increasing, but is not widespread in the United States. This AJR Expert Panel Narrative Review explores the present status and future directions of FES PET/CT, including image interpretation, existing and emerging uses, knowledge gaps, and current controversies. Specific controversies discussed include whether both FES PET/CT and FDG PET/CT are warranted in certain scenarios, whether further workup is required after negative FES PET/CT results, whether FES PET/CT findings should inform endocrine therapy selection, and whether immunohistochemistry should remain the standalone reference standard for determining ER status for all breast cancers. Consensus opinions from the panel include agreement with the appropriate clinical uses of FES PET/CT published by a multidisciplinary expert workgroup in 2023; anticipated expanded clinical use of FES PET/CT for staging ER-positive invasive lobular carcinomas and low-grade invasive ductal carcinomas pending ongoing clinical trial results; and the need for further research regarding use of FES PET/CT for ER-expressing nonbreast malignancies.
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Affiliation(s)
- Matthew F Covington
- Center for Quantitative Cancer Imaging, Huntsman Cancer Institute
- Department of Radiology and Imaging Sciences, University of Utah
| | - Sophia R O'Brien
- Department of Radiology, Hospital of the University of Pennsylvania
| | - Courtney Lawhn-Heath
- Department of Radiology and Biomedical Imaging, University of California San Francisco
| | - Austin R Pantel
- Department of Radiology, Hospital of the University of Pennsylvania
| | - Gary A Ulaner
- Molecular Imaging and Therapy, Hoag Family Cancer Institute
- Radiology and Translational Genomics, University of Southern California, Los Angeles, CA
| | - Hannah M Linden
- Department of Medicine, Division of Hematology and Oncology University of Washington, and Fred Hutchinson Cancer Center
| | - Farrokh Dehdashti
- Mallinckrodt Institute of Radiology, Siteman Cancer Center, Washington University in St. Louis
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2
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Ge Y, Ni X, Li J, Ye M, Jin X. Roles of estrogen receptor α in endometrial carcinoma (Review). Oncol Lett 2023; 26:530. [PMID: 38020303 PMCID: PMC10644365 DOI: 10.3892/ol.2023.14117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Endometrial carcinoma (EC) is a group of endometrial epithelial malignancies, most of which are adenocarcinomas and occur in perimenopausal and postmenopausal women. It is one of the most common carcinomas of the female reproductive system. It has been shown that the occurrence and development of EC is closely associated with the interaction between estrogen (estradiol, E2) and estrogen receptors (ERs), particularly ERα. As a key nuclear transcription factor, ERα is a carcinogenic factor in EC. Its interactions with upstream and downstream effectors and co-regulators have important implications for the proliferation, metastasis, invasion and inhibition of apoptosis of EC. In the present review, the structure of ERα and the regulation of ERα in multiple dimensions are described. In addition, the classical E2/ERα signaling pathway and the crosstalk between ERα and other EC regulators are elucidated, as well as the therapeutic targeting of ERα, which may provide a new direction for clinical applications of ERα in the future.
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Affiliation(s)
- Yidong Ge
- Department of Medical Oncology, The First Hospital of Ningbo University, Ningbo University, Ningbo, Zhejiang 315020, P.R. China
- Zhejiang Key Laboratory of Pathophysiology, Department of Biochemistry and Molecular Biology, Health Science Center, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Xiaoqi Ni
- Department of Medical Oncology, The First Hospital of Ningbo University, Ningbo University, Ningbo, Zhejiang 315020, P.R. China
- Zhejiang Key Laboratory of Pathophysiology, Department of Biochemistry and Molecular Biology, Health Science Center, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Jingyun Li
- Department of Medical Oncology, The First Hospital of Ningbo University, Ningbo University, Ningbo, Zhejiang 315020, P.R. China
- Zhejiang Key Laboratory of Pathophysiology, Department of Biochemistry and Molecular Biology, Health Science Center, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Meng Ye
- Department of Medical Oncology, The First Hospital of Ningbo University, Ningbo University, Ningbo, Zhejiang 315020, P.R. China
- Zhejiang Key Laboratory of Pathophysiology, Department of Biochemistry and Molecular Biology, Health Science Center, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
| | - Xiaofeng Jin
- Department of Medical Oncology, The First Hospital of Ningbo University, Ningbo University, Ningbo, Zhejiang 315020, P.R. China
- Zhejiang Key Laboratory of Pathophysiology, Department of Biochemistry and Molecular Biology, Health Science Center, Ningbo University, Ningbo, Zhejiang 315211, P.R. China
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3
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Huang YT, Chen TWW, Chen LY, Huang YY, Lu YS. The Application of 18F-FES PET in Clinical Cancer Care: A Systematic Review. Clin Nucl Med 2023:00003072-990000000-00634. [PMID: 37482660 DOI: 10.1097/rlu.0000000000004760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
INTRODUCTION [18F]fluoroestradiol (FES) can be used for the noninvasive visualization and quantification of tumor estrogen receptor (ER) expression and activity and was FDA-approved as a diagnostic agent in May 2022 for detecting ER-positive lesions in patients with recurrent or metastatic breast cancer. PET imaging was also used to detect ER-positive lesions and malignancy among patients with uterine, ovarian, and other ER-positive solid tumors. We conducted a systemic review of the studies on FES PET imaging used among patients with cancer not limited to breast cancer to better understand the application of FES PET imaging. METHODS PubMed/MEDLINE and Cochrane Library databases were used to perform a comprehensive and systematic search and were updated until August 15, 2022. Two authors independently reviewed the titles and abstracts of the retrieved articles by using the search algorithm and selected the articles based on the inclusion and exclusion criteria. All statistical analyses were conducted using R statistical software. RESULTS Forty-three studies with 2352 patients were included in the qualitative synthesis, and 23 studies with 1388 patients were included in the quantitative analysis, which estimated the FES-positive detection rate. Thirty-two studies (77%) included breast cancer patients in 43 included studies. The FES SUVmean was higher in patients with endometrial cancer (3.4-5.3) than in those with breast cancer (2.05) and uterine sarcoma (1.1-2.6). The pooled detection rates of FES PET imaging were 0.80 for breast and 0.84 for ovarian cancer patients, both similar to that of 18F-FDG. The FES uptake threshold of 1.1 to 1.82 could detect 11.1% to 45% ER heterogeneity, but the threshold of FES uptake did not have consistent predictive ability for prognosis among patients with breast cancer, unlike uterine cancer. However, FES uptake can effectively predict and monitor treatment response, especially endocrine therapy such as estradiol, ER-blocking agents (fulvestrant and tamifoxen), and aromatase inhibitors (such as letrozole and Z-endoxifen). CONCLUSIONS [18F]fluoroestradiol PET is not only a convenient and accurate diagnostic imaging tool for detecting ER-expressing lesions in patients with breast and ovarian cancer but also among patients with uterine cancer. [18F]fluoroestradiol PET is a noninvasive predictive and monitoring tool for treatment response and prognosis.
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Affiliation(s)
| | | | - Li-Yu Chen
- From the Primo Biotechnology Co, Ltd, Taipei
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4
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O'Brien SR, Edmonds CE, Lanzo SM, Weeks JK, Mankoff DA, Pantel AR. 18F-Fluoroestradiol: Current Applications and Future Directions. Radiographics 2023; 43:e220143. [PMID: 36821506 DOI: 10.1148/rg.220143] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
In the United States, breast cancer is the second leading cause of cancer death in all women and the leading cause of cancer death in Black women. The breast cancer receptor profile, assessed with immunohistochemical staining of tissue samples, allows prediction of outcomes and direction of patient treatment. Approximately 80% of newly diagnosed breast cancers are hormone receptor (HR) positive, which is defined as estrogen receptor (ER) and/or progesterone receptor (PR) positive. Patients with ER-positive disease can be treated with therapies targeting the ER; however, the assessment of ER expression with immunohistochemical staining of biopsy specimens has several limitations including sampling error, false-negative results, challenging or inaccessible biopsy sites, and the inability to synchronously and serially assess all metastatic sites to identify spatial and/or temporal ER heterogeneity. In May 2020, after decades of research, the U.S. Food and Drug Administration approved the PET radiotracer fluorine 18 (18F) fluoroestradiol (FES) for clinical use in patients with ER-positive recurrent or metastatic breast cancer as an adjunct to biopsy. FES binds to the ER in the nucleus of ER-expressing cells, enabling whole-body in vivo assessment of ER expression. This article is focused on the approved uses of FES in the United States, including identification of a target lesion for confirmatory biopsy, in vivo assessment of biopsy-proven ER-positive disease, and evaluation of spatial and temporal ER heterogeneity. FES is an example of precision medicine that has been leveraged to optimize the care of patients with breast cancer. © RSNA, 2023 See the invited commentary by Fowler in this issue. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Sophia R O'Brien
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
| | - Christine E Edmonds
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
| | - Shannon M Lanzo
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
| | - Joanna K Weeks
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
| | - David A Mankoff
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
| | - Austin R Pantel
- From the Department of Radiology, Division of Breast Imaging (S.R.O., C.E.E.) and Division of Nuclear Medicine Imaging and Therapy (S.R.O., S.M.L., J.K.W., D.A.M., A.R.P.), Hospital of the University of Pennsylvania, 3400 Spruce St, 1 Silverstein-Radiology Administration, Philadelphia, PA 19104
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5
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Parent EE, Fowler AM. Nuclear Receptor Imaging In Vivo-Clinical and Research Advances. J Endocr Soc 2022; 7:bvac197. [PMID: 36655003 PMCID: PMC9838808 DOI: 10.1210/jendso/bvac197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Indexed: 01/01/2023] Open
Abstract
Nuclear receptors are transcription factors that function in normal physiology and play important roles in diseases such as cancer, inflammation, and diabetes. Noninvasive imaging of nuclear receptors can be achieved using radiolabeled ligands and positron emission tomography (PET). This quantitative imaging approach can be viewed as an in vivo equivalent of the classic radioligand binding assay. A main clinical application of nuclear receptor imaging in oncology is to identify metastatic sites expressing nuclear receptors that are targets for approved drug therapies and are capable of binding ligands to improve treatment decision-making. Research applications of nuclear receptor imaging include novel synthetic ligand and drug development by quantifying target drug engagement with the receptor for optimal therapeutic drug dosing and for fundamental research into nuclear receptor function in cells and animal models. This mini-review provides an overview of PET imaging of nuclear receptors with a focus on radioligands for estrogen receptor, progesterone receptor, and androgen receptor and their use in breast and prostate cancer.
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Affiliation(s)
- Ephraim E Parent
- Mayo Clinic Florida, Department of Radiology, Jacksonville, Florida 32224, USA
| | - Amy M Fowler
- Correspondence: Amy M. Fowler, MD, PhD, Department of Radiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, Madison, WI 53792-3252, USA.
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6
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PET Imaging of Estrogen Receptors for Gynecological Tumors. Clin Nucl Med 2022; 47:e481-e488. [PMID: 35675139 DOI: 10.1097/rlu.0000000000004258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT In the past few decades, PET with 18F-FDG has been used for the diagnosis of gynecological malignancies and is considered to be superior to conventional imaging methods in diagnostic accuracy for detecting metastatic lesions and local recurrence and in evaluating the treatment response. On the other hand, several gynecological tumors, such as endometrial cancer and leiomyoma, and breast cancer are estrogen-dependent, in which estrogen is essential for their development and progression. 18F-FES is an 18F-labeled compound of estradiol, the most bioactive type of estrogen, and 18F-FES PET has been well-established for diagnosis, staging, and posttherapeutic follow-up in patients with estrogen receptor-positive breast cancer. Compared with in vitro assessment of tumor biopsy material, PET imaging has the advantages of being able to measure in vivo tumor behavior, characterize the entire tumor burden, and capture the heterogeneity of the tumor phenotype. In this article, we review the phenotyping of estrogen-related gynecological tumors other than breast cancer using 18F-FES PET and demonstrate the additional value of 18F-FES PET to 18F-FDG PET in their diagnosis and prognostication. Moreover, promising PET tracers other than 18F-FES and 18F-FDG for the evaluation of estrogen-related gynecological tumors are introduced.
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7
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O’Brien SR, Edmonds CE, Katz D, Mankoff DA, Pantel AR. 18F-Fluoroestradiol (FES) PET/CT: review of current practice and future directions. Clin Transl Imaging 2022. [DOI: 10.1007/s40336-022-00494-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Kumar M, Salem K, Jeffery JJ, Fowler AM. PET Imaging of Estrogen Receptors Using 18F-Based Radioligands. METHODS IN MOLECULAR BIOLOGY (CLIFTON, N.J.) 2022; 2418:129-151. [PMID: 35119664 DOI: 10.1007/978-1-0716-1920-9_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In vivo molecular imaging of estrogen receptor alpha (ER) can be performed via positron emission tomography (PET) using ER-specific radioligands, such as 16α-[18F]fluoro-17β-estradiol (18F-FES). 18F-FES is a radiopharmaceutical recently approved by the United States Food and Drug Administration for use with PET imaging to detect ER+ lesions in patients with recurrent or metastatic breast cancer as an adjunct to biopsy. 18F-FES PET imaging has been used in clinical studies and preclinical research to assess whole-body ER protein expression and ligand binding function across multiple metastatic sites, to demonstrate inter-tumoral and temporal heterogeneity of ER expression, to quantify the pharmacodynamic effects of ER antagonist treatment, and to predict endocrine therapy response. 18F-FES PET has also been studied for imaging ER in endometrial and ovarian cancer. This chapter details the experimental protocol for 18F-FES PET imaging of ER in preclinical tumor xenograft models. Consistent adherence to key methodologic details will facilitate obtaining meaningful and reproducible 18F-FES PET preclinical imaging results, which could yield additional insight for clinical trials regarding imaging biomarkers and oncologic therapy.
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Affiliation(s)
- Manoj Kumar
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Radiology, Canary Center at Stanford for Cancer Early Detection, Stanford School of Medicine, Palo Alto, CA, USA
| | - Kelley Salem
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Amy M Fowler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA.
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
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9
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Serkova NJ, Glunde K, Haney CR, Farhoud M, De Lille A, Redente EF, Simberg D, Westerly DC, Griffin L, Mason RP. Preclinical Applications of Multi-Platform Imaging in Animal Models of Cancer. Cancer Res 2021; 81:1189-1200. [PMID: 33262127 PMCID: PMC8026542 DOI: 10.1158/0008-5472.can-20-0373] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 06/10/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022]
Abstract
In animal models of cancer, oncologic imaging has evolved from a simple assessment of tumor location and size to sophisticated multimodality exploration of molecular, physiologic, genetic, immunologic, and biochemical events at microscopic to macroscopic levels, performed noninvasively and sometimes in real time. Here, we briefly review animal imaging technology and molecular imaging probes together with selected applications from recent literature. Fast and sensitive optical imaging is primarily used to track luciferase-expressing tumor cells, image molecular targets with fluorescence probes, and to report on metabolic and physiologic phenotypes using smart switchable luminescent probes. MicroPET/single-photon emission CT have proven to be two of the most translational modalities for molecular and metabolic imaging of cancers: immuno-PET is a promising and rapidly evolving area of imaging research. Sophisticated MRI techniques provide high-resolution images of small metastases, tumor inflammation, perfusion, oxygenation, and acidity. Disseminated tumors to the bone and lung are easily detected by microCT, while ultrasound provides real-time visualization of tumor vasculature and perfusion. Recently available photoacoustic imaging provides real-time evaluation of vascular patency, oxygenation, and nanoparticle distributions. New hybrid instruments, such as PET-MRI, promise more convenient combination of the capabilities of each modality, enabling enhanced research efficacy and throughput.
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Affiliation(s)
- Natalie J Serkova
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
- Animal Imaging Shared Resource, University of Colorado Cancer Center, Aurora, Colorado
| | - Kristine Glunde
- Division of Cancer Imaging Research, The Russell H. Morgan Department of Radiology, and the Sydney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Chad R Haney
- Center for Advanced Molecular Imaging, Northwestern University, Evanston, Illinois
| | | | | | | | - Dmitri Simberg
- Department of Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David C Westerly
- Animal Imaging Shared Resource, University of Colorado Cancer Center, Aurora, Colorado
- Department of Radiation Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lynn Griffin
- Department of Radiology, Veterinary Teaching Hospital, Colorado State University, Fort Collins, Colorado
| | - Ralph P Mason
- Department of Radiology, University of Texas Southwestern, Dallas, Texas
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10
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Yamada S, Tsuyoshi H, Yamamoto M, Tsujikawa T, Kiyono Y, Okazawa H, Yoshida Y. Prognostic Value of 16α- 18F-Fluoro-17β-Estradiol PET as a Predictor of Disease Outcome in Endometrial Cancer: A Prospective Study. J Nucl Med 2020; 62:636-642. [PMID: 33008930 DOI: 10.2967/jnumed.120.244319] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 09/02/2020] [Indexed: 11/16/2022] Open
Abstract
The purpose of this study was to evaluate the potential of 16α-18F-fluoro-17β-estradiol (18F-FES) PET to predict prognosis in patients with endometrial cancer (EC). Methods: In total, 67 patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-IV EC underwent 18F-FES and 18F-FDG PET/CT before treatment. The SUVmean of the primary tumor was compared with the clinical characteristics, and the relationships between SUV and progression-free survival (PFS) or overall survival were analyzed. Results: 18F-FES SUV was significantly associated with stage, histology, lymphovascular space involvement (LVSI), and lymph node metastasis, and 18F-FDG SUV was significantly associated with stage, myometrial invasion, tumor size, and lymph node metastasis. Receiver-operating characteristic curve analysis revealed that 18F-FES SUV could significantly detect tumor progression and survival, with areas under the curve of 0.813 and 0.790, respectively, whereas 18F-FDG SUV could detect them with areas under the curve of 0.557 and 0.635, respectively. The Kaplan-Meier survival curve showed that patients with a low 18F-FES SUV had significantly poor PFS (P < 0.001) and overall survival (P = 0.001) compared with patients with a high SUV, whereas 18F-FDG showed no significant differences. In a subanalysis of 27 patients with a low risk of recurrence (FIGO stage IA endometrioid carcinoma [grade 1 or 2] without LVSI), those with a low 18F-FES SUV also had poorer PFS than those with a high SUV (P = 0.002). In multivariate analysis, an 18F-FES SUV of less than 2.63 (P = 0.037; hazard ratio, 10.727; 95% CI, 1.16-99.35) and FIGO stages III and IV (P = 0.042; hazard ratio, 8.838; 95% CI, 1.09-71.84) were significantly associated with PFS. Conclusion: A low 18F-FES for the primary tumor was strongly associated with prognostic factors of EC such as LVSI and lymph node metastasis, and a low 18F-FES SUV was an independent prognostic factor for PFS in patients with EC. These data suggest that pretreatment 18F-FES PET might be useful in determining the appropriate treatment for patients with EC.
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Affiliation(s)
- Shizuka Yamada
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan; and
| | - Hideaki Tsuyoshi
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan; and
| | - Makoto Yamamoto
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan; and
| | - Tetsuya Tsujikawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Yasushi Kiyono
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Hidehiko Okazawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology, Faculty of Medical Sciences, University of Fukui, Fukui, Japan; and
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11
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Jiang X, Li Y, Wang X, Shen T, Li X, Yao Y, Zhang G, Kou Y, Shen J, Luo Z, Cheng Z. Quick Automatic Synthesis of Solvent-Free 16α-[ 18F] Fluoroestradiol: Comparison of Kryptofix 222 and Tetrabutylammonium Bicarbonate. Front Oncol 2020; 10:577979. [PMID: 33102235 PMCID: PMC7546761 DOI: 10.3389/fonc.2020.577979] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 08/17/2020] [Indexed: 11/13/2022] Open
Abstract
Estrogen receptor (ER) expression level of human breast cancer often reflects the stage of disease and is usually monitored by immunohistochemical staining in vitro. The preferable non-invasive and real-time diagnosis in vivo is more accessible by PET scan using 16α-[18F]FES. The objective of this study was to develop a quick automatic method for synthesis of solvent-free 16α-[18F]FES using a CFN-MPS-200 synthesis system and compare the catalytic efficiency of two phase transfer catalysts, Kryptofix 222/K2CO3 (K222/K2CO3) and tetrabutylammonium hydrogen carbonate (TBA·HCO3). In this method, phase transfer catalysts K222/K2CO3 and TBA·HCO3 were used, respectively. The intermediate products were both hydrolyzed with hydrochloric acid and neutralized with sodium bicarbonate. The crude product was purified with semi-preparative HPLC, and the solvent was removed by rotary evaporation. The effects of radiofluorination temperature and time on the synthesis were also investigated. Radiochemical purity of solvent-free product was above 99% and the decay-corrected radiochemical yield of 16α-[18F]FES was obtained in 48.7 ± 0.95% (catalyzed by K222/K2CO3, n = 4) and 46.7 ± 0.77% (catalyzed by TBA·HCO3, n = 4, respectively). The solvent-free 16α-[18F]FES was studied in clinically diagnosed breast cancer patients, and FES-PET results were compared with pathology diagnosis results to validate the diagnosis value of 16α-[18F]FES. The new method was more reliable, efficient, and time-saving. There was no significant difference in catalytic activity between K222/K2CO3 and TBA·HCO3.
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Affiliation(s)
- Xiao Jiang
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Institute of Isotope, China Institute of Atomic Energy, Beijing, China
| | - Yingchun Li
- Department of Nuclear Medicine & Radiotherapy, Air Force Hospital of Western Theater Command, Chengdu, China
| | - Xiaoxiong Wang
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Taipeng Shen
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Xiuli Li
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Yutang Yao
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Ge Zhang
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Ying Kou
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Jiaqi Shen
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhifu Luo
- Institute of Isotope, China Institute of Atomic Energy, Beijing, China
| | - Zhuzhong Cheng
- PET/CT Center, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China.,Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Center, School of Medicine, Sichuan Cancer Hospital & Institute, University of Electronic Science and Technology of China, Chengdu, China
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Espedal H, Fonnes T, Fasmer KE, Krakstad C, Haldorsen IS. Imaging of Preclinical Endometrial Cancer Models for Monitoring Tumor Progression and Response to Targeted Therapy. Cancers (Basel) 2019; 11:cancers11121885. [PMID: 31783595 PMCID: PMC6966645 DOI: 10.3390/cancers11121885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 11/22/2019] [Accepted: 11/25/2019] [Indexed: 12/11/2022] Open
Abstract
Endometrial cancer is the most common gynecologic malignancy in industrialized countries. Most patients are cured by surgery; however, about 15% of the patients develop recurrence with limited treatment options. Patient-derived tumor xenograft (PDX) mouse models represent useful tools for preclinical evaluation of new therapies and biomarker identification. Preclinical imaging by magnetic resonance imaging (MRI), positron emission tomography-computed tomography (PET-CT), single-photon emission computed tomography (SPECT) and optical imaging during disease progression enables visualization and quantification of functional tumor characteristics, which may serve as imaging biomarkers guiding targeted therapies. A critical question, however, is whether the in vivo model systems mimic the disease setting in patients to such an extent that the imaging biomarkers may be translatable to the clinic. The primary objective of this review is to give an overview of current and novel preclinical imaging methods relevant for endometrial cancer animal models. Furthermore, we highlight how these advanced imaging methods depict pathogenic mechanisms important for tumor progression that represent potential targets for treatment in endometrial cancer.
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Affiliation(s)
- Heidi Espedal
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, 5021 Bergen, Norway
- Correspondence: (H.E.); (I.S.H.)
| | - Tina Fonnes
- Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, 5021 Bergen, Norway; (T.F.); (C.K.)
- Department of Obstetrics and Gynecology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Kristine E. Fasmer
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Camilla Krakstad
- Centre for Cancer Biomarkers, Department of Clinical Science, University of Bergen, 5021 Bergen, Norway; (T.F.); (C.K.)
- Department of Obstetrics and Gynecology, Haukeland University Hospital, 5021 Bergen, Norway
| | - Ingfrid S. Haldorsen
- Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway;
- Mohn Medical Imaging and Visualization Centre, Department of Radiology, Haukeland University Hospital, 5021 Bergen, Norway
- Correspondence: (H.E.); (I.S.H.)
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13
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Bădan MI, Bonci EA, Piciu D. A review on immunohistochemical and histopathologic validation in PET-CT findings with consideration to microRNAs. Med Pharm Rep 2019; 92:337-345. [PMID: 31750432 PMCID: PMC6853049 DOI: 10.15386/mpr-1341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 06/20/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose This review provides an overview of some of the most recent clinical trials which investigated various types of cancer and other diseases, through the use of PET-CT imaging, highlighting the use of immunohistochemical stains or conventional histopathology for the validation or contradiction of their hypothesis. Furthermore, we investigate a potential new direction of research by analyzing the upcoming role of microRNAs in disease confirmation. Methods An extensive search of MEDLINE/PubMed and SCOPUS electronic databases was made, using the MeSH terms "positron emission tomography computed tomography" and "immunohistochemistry" as well as "SUV" and "immunohistochemistry", restricting the search by clinical trials and time period. Further searches were made for articles regarding Ki-67 and microRNAs in correlation with metabolic PET-CT uptake. Results Out of all 389 initial search results, 27 original articles were found relevant to the topic. Their contents were synthesized and discussed regarding the matter at hand. No relevant clinical trials involving microRNAs were found. Conclusions Immunohistochemical and histopathologic results remain widely used and indispensable in modern research, concerning PET-CT validation. Possible candidates for diagnosis confirmation, in future research, may reside in the further development of microRNAs.
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Affiliation(s)
- Marius-Ioan Bădan
- Department of Morphological Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Eduard-Alexandru Bonci
- Department of Morphological Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Doina Piciu
- Department of Morphological Sciences, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Department of Endocrinology and Nuclear Medicine, "Prof. Dr. Ion Chiricuta" Institute of Oncology, Cluj-Napoca, Romania
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14
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Predictive Value of 16α-[18F]-Fluoro-17β-Estradiol PET as a Biomarker of Progestin Therapy Resistance in Patients With Atypical Endometrial Hyperplasia and Low-Grade Endometrial Cancer. Clin Nucl Med 2019; 44:574-575. [PMID: 31107747 DOI: 10.1097/rlu.0000000000002612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
For early-stage endometrial cancer patients who wish to preserve fertility, progestin treatment is effective. However, repeated endometrial curettage to evaluate treatment response may cause infertility. The clinical courses of 3 patients who were treated with fertility-sparing progestin treatment and underwent serial F-FES PET before and after treatment are presented. The SUVmean decreased greatly in patients with pathologically complete response (44.2%, 46.2%), whereas there was only a small change (22.5%) in the patient with pathologically stable disease who finally underwent hysterectomy. F-FES PET can be a noninvasive method to evaluate response to fertility-sparing progestin treatment.
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15
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Linked Hexokinase and Glucose-6-Phosphatase Activities Reflect Grade of Ovarian Malignancy. Mol Imaging Biol 2019; 21:375-381. [PMID: 29987620 DOI: 10.1007/s11307-018-1247-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
PURPOSE Malignant cells exhibit increased rates of aerobic glycolysis. Here, we tested whether the accumulation of fluoro-deoxyglucose-6-phosphate (FDG6P) in ovarian cancers of differential malignancy reflects inversely correlated elevations of hexokinase (HK) and glucose-6-phosphatase (G6Pase) activities. PROCEDURES Twenty-nine women with suspected ovarian cancer had positron emission tomography (PET) prior to surgery. From fresh-frozen tissue, we determined the activities of HK and G6Pase, and from the PET images, we determined the tumor maximum standardized uptake value (SUVmax) of 2-deoxy-2-[18F]fluoro-D-glucose. RESULTS The SUVmax of malignant lesions significantly exceeded the SUVmax of benign (p < 0.005) and borderline lesions (p < 0.0005) that did not differ significantly. We found no significant correlation between measured HK or G6Pase activities and histological tumor type or SUVmax except that G6Pase activities were higher in malignant than borderline lesions (p < 0.05). Measured HK and G6Pase activities correlated inversely (p < 0.05). The slopes from the regression lines of the three correlations yielded positively correlated abscissa and ordinate intercepts, designated HKmax and G6Pasemax, respectively (r = 0.67, p < 0.0001). The positive correlations between the abscissa and ordinate intercepts with SUVmax had regression coefficients of r = 0.44, p < 0.05; and r = 0.39, p < 0.05, respectively. CONCLUSIONS The results distinguished two ovarian cancer phenotypes, one with elevated HK activity and low G6Pase activity, and another with the opposite characteristics.
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van Weelden WJ, Massuger LFAG, Pijnenborg JMA, Romano A. Anti-estrogen Treatment in Endometrial Cancer: A Systematic Review. Front Oncol 2019; 9:359. [PMID: 31134155 PMCID: PMC6513972 DOI: 10.3389/fonc.2019.00359] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/18/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction: Hormonal therapy in endometrial cancer (EC) is used for patients who wish to preserve fertility and for patients with advanced or recurrent disease in a palliative setting. First line hormonal therapy consists of treatment with progestins, which has a response rate of 25% in an unselected population. Treatment with anti-estrogens is an alternative hormonal therapy option, but there is limited data on the effect and side-effects of anti-estrogens in EC. Therefore, we performed a systematic review to investigate the response rate and toxicity of anti-estrogenic therapy in patients with endometrial cancer. Methods: A systematic search in electronic databases was performed to identify studies on selective estrogen receptor modulators (SERM) and down-regulators (SERD) and aromatase inhibitors that reported on response rates (RR) among EC patients. Outcome in estrogen receptor (ER) positive and negative disease was assessed independently. Results: Sixteen studies on advanced stage and recurrent EC were included. Ten studies investigated anti-estrogen monotherapy and seven investigated a combination of anti-estrogenic drugs with either progestin or targeted treatment. Due to heterogeneity in patient population, no meta-analysis was performed. The median age of the patients in the included studies ranged from 61 to 71 years and the proportion of low grade tumors ranged from 38 to 80%. The RR for tamoxifen ranged from 10 to 53%, for other SERMs and SERDs 9–31%, for aromatase inhibitors from 8 to 9%, for combined tamoxifen/progestin treatment 19–58%, for combined chemo- and hormonal therapy 43% and for combination of anti-estrogenic treatment with mammalian target of rapamycin (mTOR) inhibitors 14–31%. Toxicity consisted mainly of nausea and thrombotic events and was higher in combination therapy of chemotherapy and hormonal therapy and hormonal therapy and mTOR inhibitors compared to other therapies. Conclusion: Tamoxifen or a combination of tamoxifen and progestin should be the preferred choice when selecting second line hormonal treatment because the RRs are similar to first line progestin treatment and the toxicity is low. The response can be optimized by selecting patients with endometrioid tumors and positive estrogen receptor status, which should be based on a pretreatment biopsy.
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Affiliation(s)
- Willem Jan van Weelden
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Leon F A G Massuger
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Johanna M A Pijnenborg
- Department of Obstetrics and Gynecology, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, Netherlands
| | - Andrea Romano
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
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Kalshetty A, Basu S. Non- 18F-2-Fluoro-2-Deoxy-d-Glucose PET/Computed Tomography in Gynecologic Oncology: An Overview of Current Status and Future Potential. PET Clin 2018; 13:239-248. [PMID: 29482752 DOI: 10.1016/j.cpet.2017.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The current status and future potential targets of non-18F-2-fluoro-2-deoxy-d-glucose (FDG) PET/computed tomography (CT) in 3 major gynecologic malignancies are discussed. Estrogen receptor-based 16alpha-18F-fluoro-17beta-estradiol (18F-FES) PET/CT has been investigated in (a) Uterine malignancies (both endometrial and myometrial pathologies) and (b) ovarian carcinoma. For uterine tumors, FDG/FES standardized uptake value and/or uptake ratio showed a positive correlation with malignant transformation (ie, endometrial carcinoma and uterine sarcoma) and higher malignant grades, whereas higher 18F-FES uptake was documented in benign pathologies (ie, endometrial hyperplasia and leiomyoma). For epithelial ovarian carcinomas, 18F-FES PET/CT can predict the response to antiestrogen therapy in platinum-resistant cases.
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Affiliation(s)
- Ashwini Kalshetty
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe Building, Jerbai Wadia Road, Parel, Mumbai 400 012, India; Homi Bhabha National Institute, Mumbai, India
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe Building, Jerbai Wadia Road, Parel, Mumbai 400 012, India; Homi Bhabha National Institute, Mumbai, India.
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18
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Khan SR, Arshad M, Wallitt K, Stewart V, Bharwani N, Barwick TD. What’s New in Imaging for Gynecologic Cancer? Curr Oncol Rep 2017; 19:85. [DOI: 10.1007/s11912-017-0640-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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19
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Tsuyoshi H, Yoshida Y. Diagnostic imaging using positron emission tomography for gynecological malignancy. J Obstet Gynaecol Res 2017; 43:1687-1699. [DOI: 10.1111/jog.13436] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 05/28/2017] [Indexed: 01/20/2023]
Affiliation(s)
- Hideaki Tsuyoshi
- Department of Obstetrics and Gynecology; University of Fukui; Fukui Japan
| | - Yoshio Yoshida
- Department of Obstetrics and Gynecology; University of Fukui; Fukui Japan
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20
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Paquette M, Lavallée É, Phoenix S, Ouellet R, Senta H, van Lier JE, Guérin B, Lecomte R, Turcotte ÉE. Improved Estrogen Receptor Assessment by PET Using the Novel Radiotracer 18F-4FMFES in Estrogen Receptor-Positive Breast Cancer Patients: An Ongoing Phase II Clinical Trial. J Nucl Med 2017; 59:197-203. [PMID: 28798032 DOI: 10.2967/jnumed.117.194654] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/26/2017] [Indexed: 01/13/2023] Open
Abstract
After encouraging preclinical and human dosimetry results for the novel estrogen receptor (ER) PET radiotracer 4-fluoro-11β-methoxy-16α-18F-fluoroestradiol (18F-4FMFES), a phase II clinical trial was initiated to compare the PET imaging diagnostic potential of 18F-4FMFES with that of 16α-18F-fluoroestradiol (18F-FES) in ER-positive (ER+) breast cancer patients. Methods: Patients diagnosed with ER+ breast cancer (n = 31) were recruited for this study, including 6 who underwent mastectomy or axillary node dissection. For each patient, 18F-FES and 18F-4FMFES PET/CT scans were done sequentially (within a week) and in random order. One hour after injection of either radiotracer, a head-to-thigh static scan with a 2-min acquisition per bed position was obtained. Blood samples were taken at different times after injection to assess each tracer metabolism by reverse-phase thin-layer chromatography. The SUVmean of nonspecific tissues and the SUVmax of the tumor were evaluated for each detected lesion, and tumor-to-nonspecific organ ratios were calculated. Results: Blood metabolite analysis 60 min after injection of the tracer showed a 2.5-fold increase in metabolic stability of 18F-4FMFES over 18F-FES. Although for most foci 18F-4FMFES PET had an SUVmax similar to that of 18F-FES PET, tumor contrast improved substantially in all cases. Lower uptake was consistently observed in nonspecific tissues for 18F-4FMFES, notably a 4-fold decrease in blood-pool activity as compared with 18F-FES. Consequently, image quality was considerably improved using 18F-4FMFES, with lower overall background activity. As a result, 18F-4FMFES successfully identified 9 more lesions than 18F-FES. Conclusion: This phase II study with ER+ breast cancer patients showed that 18F-4FMFES PET achieves a lower nonspecific signal and better tumor contrast than 18F-FES PET, resulting in improved diagnostic confidence and lower false-negative diagnoses.
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Affiliation(s)
- Michel Paquette
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Éric Lavallée
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Serge Phoenix
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - René Ouellet
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Helena Senta
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Johan E van Lier
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Brigitte Guérin
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Roger Lecomte
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Éric E Turcotte
- Sherbrooke Molecular Imaging Center, Research Center of the Sherbrooke University Hospital (CRCHUS), and Department of Nuclear Medicine and Radiobiology, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Recommendations and Technical Aspects of 16α-[18F]Fluoro-17β-Estradiol PET to Image the Estrogen Receptor In Vivo. Clin Nucl Med 2016; 41:844-851. [DOI: 10.1097/rlu.0000000000001347] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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22
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Liao GJ, Clark AS, Schubert EK, Mankoff DA. 18F-Fluoroestradiol PET: Current Status and Potential Future Clinical Applications. J Nucl Med 2016; 57:1269-75. [DOI: 10.2967/jnumed.116.175596] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 05/16/2016] [Indexed: 11/16/2022] Open
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Merchant S, Allott L, Carroll L, Tittrea V, Kealey S, Witney TH, Miller PW, Smith G, Aboagye EO. Synthesis and pre-clinical evaluation of a [18F]fluoromethyl-tanaproget derivative for imaging of progesterone receptor expression. RSC Adv 2016. [DOI: 10.1039/c6ra07404a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This work features the synthesis and biological evaluation of a novel fluorinated derivative of tanaproget and a carbon-11 labelled analogue, a high affinity non-steroidal PR ligand, as a possible candidate for imaging PR expressionin vivo.
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Affiliation(s)
- Shairoz Merchant
- Comprehensive Cancer Imaging Centre
- Department of Surgery and Cancer
- Imperial College London
- London
- UK
| | - Louis Allott
- Division of Radiotherapy and Imaging
- The Institute of Cancer Research
- London
- UK
| | - Laurence Carroll
- Comprehensive Cancer Imaging Centre
- Department of Surgery and Cancer
- Imperial College London
- London
- UK
| | - Vickram Tittrea
- Comprehensive Cancer Imaging Centre
- Department of Surgery and Cancer
- Imperial College London
- London
- UK
| | - Steven Kealey
- Department of Chemistry
- Imperial College London
- London
- UK
| | - Timothy H. Witney
- Comprehensive Cancer Imaging Centre
- Department of Surgery and Cancer
- Imperial College London
- London
- UK
| | | | - Graham Smith
- Division of Radiotherapy and Imaging
- The Institute of Cancer Research
- London
- UK
| | - Eric O. Aboagye
- Comprehensive Cancer Imaging Centre
- Department of Surgery and Cancer
- Imperial College London
- London
- UK
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Deng SM, Zhang W, Zhang B, Chen YY, Li JH, Wu YW. Correlation between the Uptake of 18F-Fluorodeoxyglucose (18F-FDG) and the Expression of Proliferation-Associated Antigen Ki-67 in Cancer Patients: A Meta-Analysis. PLoS One 2015; 10:e0129028. [PMID: 26038827 PMCID: PMC4454667 DOI: 10.1371/journal.pone.0129028] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/04/2015] [Indexed: 12/22/2022] Open
Abstract
Objective To study the correlation between 18F-FDG uptake and cell proliferation in cancer patients by meta-analysis of published articles. Methods We searched PubMed (MEDLINE included), EMBASE, and Cochrane Database of Systematic Review, and selected research articles on the relationship between 18F-FDG uptake and Ki-67 expression (published between August 1, 1994-August 1, 2014), according to the literature inclusion and exclusion criteria. The publishing language was limited to English. The quality of included articles was evaluated according to the Quality Assessment of Diagnosis Accuracy Studies-2 (QUADAS-2). The correlation coefficient (r) was extracted from the included articles and processed by Fisher's r-to-z transformation. The combined correlation coefficient (r) and the 95% confidence interval (CI) were calculated with STATA 11.0 software under a random-effects model. Begg's test was used to analyze the existence of publication bias and draw funnel plot, and the sources of heterogeneity were explored by sensitivity and subgroup analyses. Results According to the inclusion and exclusion criteria, 79 articles were finally included, including 81 studies involving a total of 3242 patients. All the studies had a combined r of 0.44 (95% CI, 0.41-0.46), but with a significant heterogeneity (I2 = 80.9%, P<0.01). Subgroup analysis for different tumor types indicated that most subgroups showed a reduced heterogeneity. Malignant melanoma (n = 1) had the minimum correlation coefficient (-0.22) between 18F-FDG uptake and Ki-67 expression, while the thymic epithelial tumors (TETs; n = 2) showed the maximum correlation coefficient of 0.81. The analytical results confirmed that correlation between 18F-FDG uptake and Ki-67 expression was extremely significant in TETs, significant in gastrointestinal stromal tumors (GISTs), moderate in patients with lung, breast, bone and soft tissue, pancreatic, oral, thoracic, and uterine and ovarian cancers, average in brain, esophageal and colorectal cancers, and poor in head and neck, thyroid, gastric and malignant melanoma tumors. Subgroup analysis indicated that positron emission tomography (PET) or PET/CT imaging technology or Ki-67 and standardized uptake value (SUV) measurement technology did not significantly affect the results of r values, and Begg's test showed no significant publication bias. Conclusion In cancer patients, 18F-FDG uptake showed a moderate positive correlation with tumor cell proliferation. Different tumor types exhibited varied degree of correlation, and the correlation was significant in TETs and GSTs. However, our results need further validation by clinical trials with a large sample of different tumor types.
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Affiliation(s)
- Sheng-ming Deng
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
- School of Radiation Medicine and Protection, Medical College of Soochow University, Suzhou, China
| | - Wei Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bin Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
- Key Laboratory of Nuclear Medicine, Ministry of Health, Jiangsu Key Laboratory of Molecular Nuclear Medicine, Jiangsu Institute of Nuclear Medicine, Wuxi, China
- * E-mail:
| | - Yin-yin Chen
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ji-hui Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yi-wei Wu
- Department of Nuclear Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China
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Alam IS, Arshad MA, Nguyen QD, Aboagye EO. Radiopharmaceuticals as probes to characterize tumour tissue. Eur J Nucl Med Mol Imaging 2015; 42:537-61. [PMID: 25647074 DOI: 10.1007/s00259-014-2984-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/18/2014] [Indexed: 01/06/2023]
Abstract
Tumour cells exhibit several properties that allow them to grow and divide. A number of these properties are detectable by nuclear imaging methods. We discuss crucial tumour properties that can be described by current radioprobe technologies, further discuss areas of emerging radioprobe development, and finally articulate need areas that our field should aspire to develop. The review focuses largely on positron emission tomography and draws upon the seminal 'Hallmarks of Cancer' review article by Hanahan and Weinberg in 2011 placing into context the present and future roles of radiotracer imaging in characterizing tumours.
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Affiliation(s)
- Israt S Alam
- Comprehensive Cancer Imaging Centre, Imperial College London, London, W12 0NN, UK
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26
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Lefebvre-Lacœuille C, Lacœuille F, Rousseau C, Courbon F, Benard F, Couturier OF. 16α-[18F]-fluoro-17ß-oestradiol ([18F]FES): A biomarker for imaging oestrogen receptor expression with positron emission tomography (PET). MEDECINE NUCLEAIRE-IMAGERIE FONCTIONNELLE ET METABOLIQUE 2015. [DOI: 10.1016/j.mednuc.2015.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Steroid hormone receptor (SHR) expression and changes in SHR expression compared to basal levels, whether upregulated, downregulated, or mutated, form a distinguishing feature of some breast, ovarian, and prostate cancers. These receptors act to induce tumor proliferation. In the imaging context, total expression together with modulation of expression can yield predictive and prognostic information. Currently, biopsy for histologic assessment of SHR expression is routine for breast and prostate cancer; however, the technique is not well suited to the heterogeneous tumor environment and can lead to incorrect receptor expression assignment, which precludes effective treatment. The development of positron emission tomography (PET) radioligands to image receptor expression may overcome the difficulties associated with tumor heterogeneity and facilitate the assessment of metastatic disease.
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Keliher EJ, Klubnick JA, Reiner T, Mazitschek R, Weissleder R. Efficient acid-catalyzed (18) F/(19) F fluoride exchange of BODIPY dyes. ChemMedChem 2014; 9:1368-73. [PMID: 24596307 DOI: 10.1002/cmdc.201300506] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 02/13/2014] [Indexed: 01/10/2023]
Abstract
Fluorine-containing fluorochromes are important validation agents for positron emission tomography imaging compounds, as they can be readily validated in cells by fluorescence imaging. In particular, the (18) F-labeled BODIPY-FL fluorophore has emerged as an important platform, but little is known about alternative (18) F-labeling strategies or labeling on red-shifted fluorophores. In this study we explore acid-catalyzed (18) F/(19) F exchange on a range of commercially available N-hydroxysuccinimidyl ester and maleimide BODIPY fluorophores. We show this method to be a simple and efficient (18) F-labeling strategy for a diverse span of fluorescent compounds, including a BODIPY-modified PARP-1 inhibitor, and amine- and thiol-reactive BODIPY fluorophores.
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Affiliation(s)
- Edmund J Keliher
- Center for Systems Biology, Massachusetts General Hospital, Richard B. Simches Research Center, 185 Cambridge Street, Boston, MA 02114 (USA)
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Ghooshkhanei H, Treglia G, Sabouri G, Davoodi R, Sadeghi R. Risk stratification and prognosis determination using 18F-FDG PET imaging in endometrial cancer patients: A systematic review and meta-analysis. Gynecol Oncol 2014; 132:669-76. [DOI: 10.1016/j.ygyno.2014.01.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 01/17/2014] [Accepted: 01/18/2014] [Indexed: 10/25/2022]
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van Kruchten M, de Vries EGE, Brown M, de Vries EFJ, Glaudemans AWJM, Dierckx RAJO, Schröder CP, Hospers GAP. PET imaging of oestrogen receptors in patients with breast cancer. Lancet Oncol 2013; 14:e465-e475. [PMID: 24079874 DOI: 10.1016/s1470-2045(13)70292-4] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Oestrogen receptors are overexpressed in around 70% of all breast cancers, and are a target for endocrine therapy. These receptors can be visualised on PET with use of 16α-[(18)F]-fluoro-17β-oestradiol ((18)F-FES) as a tracer. Compared with biopsy, which enables assessment of individual sites, whole-body (18)F-FES-PET enables quantification of oestrogen-receptor expression in all metastases. In several studies, measurement of tumour protein expression in oestrogen receptors by (18)F-FES-PET, concurrent with biopsy, detected oestrogen-receptor-positive tumour lesions with a sensitivity of 84% and specificity of 98%. Roughly 45% of patients with metastatic breast cancer have discordant oestrogen-receptor expression across lesions (ie, (18)F-FES-positive and (18)F-FES-negative metastases). Low tumour (18)F-FES uptake in metastases can predict failure of hormonal therapy in patients with oestrogen-receptor-positive primary tumours. Finally, (18)F-FES-PET has shown that oestrogen-receptor binding capacity changes after intervention with hormonal drugs, but findings need to be confirmed. Factors other than oestrogen-receptor expression, including menopausal status and concomitant therapies, that can affect tumour (18)F-FES uptake must be taken into account.
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Affiliation(s)
- Michel van Kruchten
- Department of Medical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Elisabeth G E de Vries
- Department of Medical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Myles Brown
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Erik F J de Vries
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Rudi A J O Dierckx
- Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Carolien P Schröder
- Department of Medical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Geke A P Hospers
- Department of Medical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands.
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Assessment of the Novel Estrogen Receptor PET Tracer 4-Fluoro-11β-methoxy-16α-[18F]fluoroestradiol (4FMFES) by PET Imaging in a Breast Cancer Murine Model. Mol Imaging Biol 2013; 15:625-32. [DOI: 10.1007/s11307-013-0638-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Zhao Z, Yoshida Y, Kurokawa T, Kiyono Y, Mori T, Okazawa H. 18F-FES and 18F-FDG PET for differential diagnosis and quantitative evaluation of mesenchymal uterine tumors: correlation with immunohistochemical analysis. J Nucl Med 2013; 54:499-506. [PMID: 23471314 DOI: 10.2967/jnumed.112.113472] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
UNLABELLED The aim of this study was to investigate the relationship between the tumor uptake of 16α-(18)F-fluoro-17β-estradiol ((18)F-FES) and (18)F-FDG using PET and expressions of sex hormone receptors, such as estrogen receptor (ER), as well as glucose transporter 1 (GLUT-1) and Ki-67 analyzed by the immunohistochemistry method in mesenchymal uterine tumors. METHODS Forty-seven patients with mesenchymal uterine tumors were studied with (18)F-FES and (18)F-FDG PET. Postoperative pathologic diagnosis revealed 33 uterine leiomyomas and 14 uterine sarcomas. Tissue samples were assayed for expression of ERα, ERβ, progesterone receptor (PR), PR-B, GLUT-1, and Ki-67 by an immunohistochemistry method. Standardized uptake values (SUVs) for (18)F-FES and (18)F-FDG were compared with the semiquantitative immunoreactive score (0-12) and quantitative labeling index (LI) for Ki-67 in immunohistochemistry. RESULTS (18)F-FES uptake was significantly lower (P < 0.001) and the (18)F-FDG uptake and SUV ratio of (18)F-FDG to (18)F-FES ((18)F-FDG/(18)F-FES ratio) (P < 0.005 and P < 0.001, respectively) were significantly higher in uterine sarcomas than in leiomyomas. Immunohistochemistry analysis showed significantly higher expressions of ERα, PR, and PR-B in uterine leiomyomas than in sarcomas. The Ki-67 LI was significantly greater in uterine sarcomas than in leiomyomas. Correlation analysis for all tumors showed positive correlations between (18)F-FES SUV and immunohistochemistry scores of ERα, PR (P < 0.001), and PR-B (P < 0.005) as well as between (18)F-FDG SUV and GLUT-1 and Ki-67 (P < 0.001). However, the (18)F-FDG/(18)F-FES ratio showed significantly negative correlations with ERα, PR (P < 0.001), and PR-B (P < 0.005) and a positive correlation with Ki-67 LI (P < 0.001). In uterine sarcomas, ERα and (18)F-FES SUV showed a positive correlation (P < 0.001) in a low SUV range, and the (18)F-FDG/(18)F-FES ratio showed positive correlations with ERβ and GLUT-1 expression (P < 0.005). CONCLUSION (18)F-FES and (18)F-FDG PET showed correlations between tracer uptake and expressions of sex hormone receptors, GLUT-1, and Ki-67 in mesenchymal uterine tumors. The (18)F-FDG/(18)F-FES ratio was correlated with Ki-67, GLUT-1, and ERβ in uterine sarcoma. Functional PET imaging and PET parameters would be useful noninvasive biomarkers for the assessment of tumor hormone receptor expression, glucose metabolism, and proliferation and for differential diagnosis of uterine leiomyoma and sarcoma.
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Affiliation(s)
- Zhenhua Zhao
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan
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Tsujikawa T, Yoshida Y, Maeda H, Tsuchida T, Mori T, Kiyono Y, Kimura H, Okazawa H. Oestrogen-related tumour phenotype: positron emission tomography characterisation with ¹⁸F-FDG and ¹⁸F-FES. Br J Radiol 2012; 85:1020-4. [PMID: 22337690 DOI: 10.1259/bjr/26645378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
This article outlines the role of 16α-[(18)F]fluoro-17β-oestradiol ((18)F-FES) positron emission tomography (PET) combined with 2-[(18)F]fluoro-2-deoxy-D-glucose ((18)F-FDG) in patients with oestrogen-related tumours for evaluating tumour phenotype. (18)F-FES-PET combined with (18)F-FDG is helpful in characterising the distinct phenotypic features of oestrogen-related tumours; that is, inter- and intrapatient tumour heterogeneity, which indicates its great potential as a determinant of individualised treatment and a prognostic predictor for patients with oestrogen-related tumours.
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Affiliation(s)
- T Tsujikawa
- Biomedical Imaging Research Center, University of Fukui, Fukui, Japan, University of Fukui, Fukui, Japan.
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Paquette M, Ouellet R, Archambault M, Croteau É, Lecomte R, Bénard F. [18F]-fluoroestradiol quantitative PET imaging to differentiate ER+ and ERα-knockdown breast tumors in mice. Nucl Med Biol 2012; 39:57-64. [DOI: 10.1016/j.nucmedbio.2011.06.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2011] [Revised: 06/24/2011] [Accepted: 06/27/2011] [Indexed: 02/01/2023]
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[FDG-PET and endometrial cancer]. Bull Cancer 2011; 99:21-8. [PMID: 22182739 DOI: 10.1684/bdc.2011.1514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
FDG-PET is widely used for the diagnosis, the staging and the search for recurrence of many tumors. However, there are currently no recommendations for its use in endometrial cancer. This article is an update of the literature data to enable everyone to form an opinion on the subject. Future prospects are considered.
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Yoshida Y, Kiyono Y, Tsujikawa T, Kurokawa T, Okazawa H, Kotsuji F. Additional value of 16α-[18F]fluoro-17β-oestradiol PET for differential diagnosis between uterine sarcoma and leiomyoma in patients with positive or equivocal findings on [18F]fluorodeoxyglucose PET. Eur J Nucl Med Mol Imaging 2011; 38:1824-31. [DOI: 10.1007/s00259-011-1851-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 05/20/2011] [Indexed: 11/30/2022]
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