The Diagnostic Accuracy of 18F-FDG PET and 18F-FES PET for Staging Grade 1-2 Estrogen Receptor-Positive Breast Cancer
Jelijn J Knip1, Ramsha Iqbal1, Emma C Bonjer1
1From the Departments of Medical Oncology (J.J.K., R.I., E.C.B., I.R.K., C.W.M.v.d.H.v.O.), Surgery (G.M.P.D., S.v.d.V.), Radiology and Nuclear Medicine (L.J.S., K.D., G.J.C.Z., A.D.W., R.B., D.E.O.L.), and Pathology (E.B.), Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Department of Imaging and Biomarkers, Cancer Center Amsterdam, Amsterdam, the Netherlands (J.J.K., R.I., I.R.K., G.J.C.Z., R.B., D.E.O.L., C.W.M.v.d.H.v.O.); Departments of Medical Oncology (L.H.M.) and Nuclear Medicine (J.J.M.T.), Reinier de Graaf Gasthuis, Delft, the Netherlands; Department of Medical Oncology, Ziekenhuis Amstelland, Amstelveen, the Netherlands (A.A.v.Z., P.P.); Department of Surgery, Flevoziekenhuis, Almere, the Netherlands (G.M.P.D.); Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands (L.J.S.); Department of Medical Oncology, Zaans Medisch Centrum, Zaandam, the Netherlands (S.D.B.); and Department of Medical Oncology, Dijklander Ziekenhuis, Hoorn, the Netherlands (N.S.).
Abstract:
Background According to current guidelines, staging of patients with locally advanced breast cancer and local-regional recurrent breast cancer is preferably performed with PET using 2-fluorine 18-fluoro-2-deoxy-d-glucose (18F-FDG). However, 18F-FDG PET might underperform in low-grade estrogen receptor (ER)-positive breast cancer. Alternatively, 16α-18F-fluoro-17β-estradiol (18F-FES) has emerged as a powerful tracer for in vivo visualization of ER-positive lesions. Purpose To assess whether 18F-FES PET improves staging of grade 1 or 2 ER-positive breast cancer compared with 18F-FDG PET. Materials and Methods Patients with clinical stage II/III or local-regional recurrent, grade 1 or 2, ER-positive breast cancer were included between December 2018 and January 2021 in this prospective multicenter pilot study. All participants underwent an 18F-FES PET examination in addition to standard staging with conventional imaging and 18F-FDG PET. Both PET scans were independently assessed. The disease stage was determined independently based on conventional imaging and 18F-FDG PET or 18F-FES PET. Relevant lesions suspected of malignancy were verified histopathologically, after which a final stage was determined. Results A total of 41 female participants (median age, 56 years [IQR, 48-71 years]) with 44 breast tumors were included. Overall, 29 of 41 participants (71%) were correctly staged at 18F-FDG PET compared with 34 of 41 (83%) at 18F-FES PET (P = .18). Seven of 10 and nine of 10 cases of lobular breast cancer were correctly staged at 18F-FDG and 18F-FES PET, respectively (70% vs 90%; P = .38) and seven of 12 and 11 of 12 cases of grade 1 tumors, respectively (58% vs 92%; P = .06). Regional lymph nodes were incorrectly staged at 18F-FDG PET in six of 44 cases (14%), whereas all cases were correctly staged at 18F-FES PET (P = .02). Both imaging methods had a sensitivity of 100% (95% CI: 59, 100) and a specificity of 91% (95% CI: 76, 98) for the detection of metastatic disease. Conclusion In this prospective pilot study, there was no evidence of a difference in diagnostic accuracy of 18F-FES PET and 18F-FDG PET in staging patients with grade 1 or 2 ER-positive breast cancer. Clinical trial registration no. NCT03726931 Published under a CC BY 4.0 license Supplemental material is available for this article. See also the editorial by Fowler in this issue.
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