Accurate staging is of great importance in patients with clinically locally advanced primary breast cancer (LABC, stage III) or locoregional recurrent (LRR) breast cancer for making a correct treatment plan. According to current guidelines, staging is performed with positron emission tomography (PET) using the 2-\[18F\]fluoro-2-deoxy-D-glucose (\[18F\]FDG) PET tracer, combined with diagnostic computed tomography (CT). However, previous studies have shown that this technique (with the current PET tracer) might not be sufficient for accurate staging. Specifically in low grade, estrogen receptor positive (ER+) breast cancer metastases can be missed due to the low metabolic activity, leading to low uptake of \[18F\]FDG. Therefore, there is a clinical need to improve staging procedures. 16α-\[18F\]-fluoro-17β-estradiol (\[18F\]FES), an ER-targeted PET tracer, allows imaging of ER+ tumor lesions regardless of their metabolic activity. Patients with clinically LABC and LRR have a 25-50% risk of distant metastases. Correct identification of distant metastases allows adaptation of the treatment plan to avoid burdensome treatment with surgery, systemic and radiotherapy in order to maintain quality of life. In case of oligometastases, correct identification increases the likelihood for cure with local treatment. In the current study we will compare disease staging with \[18F\]FES- and \[18F\]FDG PET in patients with clinically LABC/LRR breast cancer. Objective: To determine whether \[18F\]FES PET/CT improves staging for women with clinically LABC or LRR, ER+/HER2- breast cancer as compared to standard \[18F\]FDG PET/CT. Study design: Multicenter prospective study with invasive measurements. Study population: 20 LABC and 20 LRR ER+/HER2- breast cancer patients. Main study parameters/endpoints: To determine the percentage of patients with a correctly changed treatment plan according to information obtained from \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT at staging and at 6 months of follow-up; to determine the percentage of metastatic lesions detected and missed with \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT (at staging and during follow-up). Nature and extent of the burden and risks associated with participation, benefit and group relatedness: Patients will receive an intravenous cannula for tracer injection and blood sampling, causing potentially transient discomfort at the site of the cannula insertion. Tumor biopsy will be performed from an easy accessible lesion and the most frequent complications that can occur are discomfort, bleeding and (local) infection. The risk of complications from a tumor biopsy is considered low: 0.24-1.6% and 0.11-0.48% for major complications and mortality, respectively. Radiation exposure from a \[18F\]FES PET and \[18F\]FDG PET scan usually ranges between 4-11 mSv and 7-8 mSv, respectively. Radiation exposure from a diagnostic CT scan ranges between 8-14 mSv. The total radiation burden is considered justifiable when compared to the information that can be obtained from this study, in this patient group with breast cancer. Imaging with \[18F\]FES PET may improve staging for patients with breast cancer as it may show tumor lesions that could not be identified with \[18F\]FDG PET, the current standard for staging. If this is the case, the initial treatment goal and intensity can be adjusted which can have beneficial effects for the patient.
Study Type
INTERVENTIONAL
Allocation
NA
Purpose
DIAGNOSTIC
Masking
NONE
Enrollment
40
\[18F\]FES PET/CT scan will be performed after administration of radioactive labelled estrogen.
VU University Medical Center
Amsterdam, North Holland, Netherlands
Percentage of patients with a correctly changed treatment plan according to [18F]FES PET/CT compared to [18F]FDG PET/CT.
Percentage of patients with a correctly changed treatment plan according to information obtained with \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT at staging.
Time frame: 2 years
Percentage of metastatic lesions detected with [18F]FES PET/CT compared to [18F]FDG PET/CT.
Percentage of metastatic lesions detected with \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT at staging.
Time frame: 2 years
Percentage of missed metastases with [18F]FES PET/CT compared to [18F]FDG PET/CT.
Percentage of missed metastases with \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT (at staging and developed during follow-up).
Time frame: 2 years
Percentage of correct treatment plans as well as diagnostic confidence after 6 months of follow-up based on the added information obtained with [18F]FES PET/CT compared to [18F]FDG PET/CT.
Percentage of correct treatment plans as well as diagnostic confidence after 6 months of follow-up as determined by the adjudication committee based on the added information obtained with \[18F\]FES PET/CT compared to \[18F\]FDG PET/CT.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to size of the lesion
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to size of the lesion.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to location of the lesion.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to location of the lesion.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to histological subtype.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to histological subtype.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to grade.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to grade.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to ER expression level.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to ER expression level.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to PR expression level.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to PR expression level.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to HER2 expression level.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to HER2 expression level.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to Ki67%/mitotic index.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to Ki67%/mitotic index.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to intensity of ER staining.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to intensity of ER staining.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to intensity of tumor cell density.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to intensity of tumor cell density.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to intensity of microvessel density.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to intensity of microvessel density.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to infiltration of lymphocytes.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to infiltration of lymphocytes.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to amount of necrosis.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to amount of necrosis.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to amount of stroma.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to amount of stroma.
Time frame: 2 years
[18F]FES/[18F]FDG uptake related to expression of glucose transporter-1 (GLUT1) in the primary tumor, lymph node and distant metastases.
\[18F\]FES/\[18F\]FDG uptake in the primary tumor, lymph node and distant metastases will be related to expression of glucose transporter-1 (GLUT1) in the primary tumor, lymph node and distant metastases.
Time frame: 2 years
Cut off value for [18F]FDG SUV max below which [18F]FES PET/CT adds information for staging.
Cut off value for \[18F\]FDG SUV max below which \[18F\]FES PET/CT adds information for staging.
Time frame: 2 years
Cut off value for [18F]FDG SUV peak below which [18F]FES PET/CT adds information for staging.
Cut off value for \[18F\]FDG SUV peak below which \[18F\]FES PET/CT adds information for staging.
Time frame: 2 years
Cut off value for grade below which or above which [18F]FES PET/CT adds information for staging.
Cut off value for grade below which or above which, respectively, \[18F\]FES PET/CT adds information for staging.
Time frame: 2 years
Cut off value for ER expression level below which or above which [18F]FES PET/CT adds information for staging.
Cut off value for ER expression level below which or above which \[18F\]FES PET/CT adds information for staging.
Time frame: 2 years
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