Diagnostic Performance of ¹⁸F-Fluoroestradiol PET/CT for Axillary Lymph Node Metastasis in Invasive Lobular...

Invasive lobular breast cancer (ILC) presents diagnostic challenges with conventional imaging modalities. We aimed to evaluate the diagnostic performance of ¹⁸F-fluoroestradiol (¹⁸F-FES) PET/CT for axillary lymph node (ALN) metastasis in ILC. Methods: This prospective feasibility study was conducted between August 2023 and August 2024. Eligible patients had newly diagnosed estrogen receptor-positive ILC, had confirmed or suspected ALN metastasis on physical examination or imaging, and were scheduled to undergo axillary surgery. The presence of metastasis in ipsilateral ALN on ¹⁸F-FES PET/CT was assessed visually and semiquantitatively (SUV_max) and compared with surgical specimens. Results: In total, 20 women were included in the analysis. Twelve patients had surgically proven ALN metastasis. On visual analysis, ¹⁸F-FES PET/CT showed a sensitivity of 67% (8/12; 95% CI, 35%-90%) and a specificity of 100% (8/8; 95% CI, 63%-100%). All 4 false-negative cases had a single metastasis on the sentinel lymph node, with sizes of 1, 1.5, 6, and 6 mm. An unexpected ¹⁸F-FES-positive ipsilateral internal mammary lymph node was detected in 1 patient. The median SUV_max was 3.4 (interquartile range, 1.2-9.5) and 1.0 (interquartile range, 0.8-1.1) for metastatic and benign ALNs, respectively. With an optimal cutoff of at least 1.2, SUV_max showed a sensitivity of 75% (9/12; 95% CI, 43%-95%) and a specificity of 100% (8/8; 95% CI, 63%-100%). The area under the receiver operating curve was 0.89 (95% CI, 0.75-1.00). Three of 4 patients with false-negative fine-needle aspiration results for ALN were positive on ¹⁸F-FES PET/CT. Conclusion: ¹⁸F-FES PET/CT had excellent specificity and moderate sensitivity for detecting ALN metastasis in ILC, suggesting its potential as a valuable staging modality for early ILC.