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1. PET/CT for patients with Breast Cancer:
Ductal and Lobular Malignancies
Gary Ulaner, M.D., Ph.D.
Associate Member, Department of Radiology

2. Disclosures
Research Grant Support:
NIH R01 (#CA204167)
Department of Defense (#W81XWH-14-1-0444)
Komen for the Cure Foundation (#KG110441)
Leukemia & Lymphoma Society (#RTF6004-19)
GE Healthcare
Genentech
Sanofi
Novartis
Puma biotechnology
Non-FDA approved PET radiotracers
18F-FACBC
18F-FES

4. Imaging for patients with breast cancer
Local Disease:
Mammography
Ultrasound
MRI
Systemic Staging of Disease:
CT and bone scan
FDG PET/CT

5. ©2009 by Radiological Society of North America
Where is the clinical value of FDG PET/CT for
patients with breast cancer?

6. Hx = multicentric L Br CA. Staging.
Bone metastasis seen only on FDG PET

7. • In advanced local breast cancer, FDG PET/CT improves detection
of distant metastases.
• FDG PET/CT changes stage in:
• 6% of stage IIA
• 15% of Stage IIB
• 28% of stage IIIA

8. • 163 patients with FDG PET/CT and Bone Scan.
• 31 discordant cases.
• 12 had pathology confirming osseous metastases.
• 9 were PET+ & BS-. 1 PET+ & BS +/-. 2 PET+/- & BS-.
• PET/CT may supplant Bone Scan for Metastatic Breast Cancer.

9. Hx = Br CA.
Increasing bone metastases
Aug 3, 2011 Nov 10, 2011

10. Comparison of FDG PET/CT vs. CECT for prediction
of survival in patients with stage 4 breast cancer
- 43% of RECIST non-responders were PERCIST responders
- PERCIST more predictive of DSS, PFS, OS
Riedl, Ulaner, et al. EJNMMI, 2017 Aug; 44(9):1420-1427.

11. ©2009 by Radiological Society of North America
Where is the clinical value of FDG PET/CT for
patients with breast cancer?
~30% of initial stage 3
patients will be upstaged to
stage 4 by FDG PET/CT.
Groheux…Mankoff JNM 2016
~15% of initial stage 2B
patients will be upstaged to
stage 4 by FDG PET/CT
Riedl…Ulaner JNM 2014.
Ulaner…Gonen EJNMMI 2016
FDG PET/CT appears to be
more accurate than CT and
bone scan for evaluating
treatment response and
recurrence.

12. • ILC is a clinically and molecularly distinct disease from IDC
• ILCs show loss of CDH1 & PTEN, AKT activation, and mutations in TBX3 & FOXA1
• ILC, on average, is less FDG-avd than
• Genetic features classify mixed tumors into lobular-like and ductal-like subgroups

13. Hx = Lobular Br CA.
2003 2010
Non-FDG-avid bone metastases.

14. Hx = Lobular Br CA.
2011
Prior
2009
Non-FDG-avid bone met.

15. Dx: Non-FDG-avid
peritoneal carcinomatosis and
retroperitoneal disease causing
hydronephrosis
Hx = Lobular Br CA.

16. - FDG-avidity of ILC < IDC
- Propensity for metastasis different (ILC vs IDC)
- ILC osseous lesions more commonly sclerotic
PET/CT has lower impact on systemic staging of ILC than IDC.

17. ©2009 by Radiological Society of North America
Where is the clinical value of FDG PET/CT for
patients with breast cancer?
~30% of initial stage 3
patients will be upstaged to
stage 4 by FDG PET/CT.
Groheux…Mankoff JNM 2016
~15% of initial stage 2B
patients will be upstaged to
stage 4 by FDG PET/CT
Riedl…Ulaner JNM 2014.
Ulaner…Gonen EJNMMI 2016
FDG PET/CT appears to be
more accurate than CT and
bone scan for evaluating
treatment response and
recurrence.
Beware of Lobular Breast Cancers

18. Molecular Imaging for Patient
Selection
Molecular Imaging
Technologies
Target 1
Target 2
Target 4
Target 3

19. Molecular Imaging for Patient
Selection
Molecular Imaging
Technologies
Target 1
Target 2
Target 4
Target 3

20. 18F labelled 1-amino-3-fluorocyclobutane
-1-carboxylic acid (FACBC, Axumin)
18F-Fluciclovine PET/CT
• Synthetic amino acid
• Actively transported by
amino acid transporters
(AATs), most notably
LAT1 and ASCT2

21. ER-targeted PET/CT
18F-Fluoroestradiol
(FES)

22. Hx: 51 y/o woman with right breast invasive lobular cancer
and right axillary nodal metastases. Initial staging.
FDG PET/CT (3/16/18) FES PET/CT (4/3/18)
Dx: Previously unsuspected, biopsy proven,
FES-avid osseous metastasis

23. Summary: PET/CT for patients with breast cancer
• FDG PET/CT is useful for systemic staging of patients with 2B-3C
breast cancer and restaging of patients with metastatic breast cancer.
• Beware of ILC that may not be FDG-avid. CT findings can identify
malignancy occult on FDG PET.
• Multiple new radiotracers are being evaluated for patients with ILC,
but these are still only research studies.