Between-patient and within-patient (site-to-site) variability in estrogen receptor binding, measured in vivo by 18F-fluoroestradiol PET

Abstract

Heterogeneity of estrogen receptor (ER) expression may be an important predictor of breast cancer therapeutic response. (18)F-fluoroestradiol PET produces in vivo quantitative measurements of regional estrogen binding in breast cancer tumors. We describe within-patient (site-to-site) and between-patient heterogeneity of lesions in patients scheduled to receive endocrine therapy.

Methods: In 91 patients with a prior ER-positive biopsy, 505 lesions were analyzed for both (18)F-fluoroestradiol and (18)F-FDG uptake and the (18)F-fluoroestradiol/(18)F-FDG uptake ratio. Standardized uptake values (SUVs) were recorded for up to 16 lesions per patient, of 1.5 cm or more and visible on (18)F-FDG PET or conventional staging. Linear mixed-effects regression models examined associations between PET parameters and patient or lesion characteristics and estimated variance components. A reader study of SUV measurements for 9 scans further examined sources of within-patient variability.

Results: Average (18)F-fluoroestradiol uptake and (18)F-fluoroestradiol/(18)F-FDG ratio varied greatly across these patients, despite a history of ER-positive disease: about 37% had low or absent (18)F-fluoroestradiol uptake even with marked (18)F-FDG uptake. (18)F-fluoroestradiol SUV and (18)F-fluoroestradiol/(18)F-FDG ratio measurements within patients with multiple lesions were clustered around the patient's average value in most cases. Summarizing these findings, the intraclass correlation coefficient (proportion of total variation that is between-patient) was 0.60 (95% confidence interval, 0.50-0.69) for (18)F-fluoroestradiol SUV and 0.65 (95% confidence interval, 0.56-0.73) for the (18)F-fluoroestradiol/(18)F-FDG ratio. Some within-patient variation in PET measures (22%-44%) was attributable to interobserver variability as measured by the reader study. A subset of patients had mixed uptake, with widely disparate (18)F-fluoroestradiol SUV or (18)F-fluoroestradiol/(18)F-FDG ratio for lesions in the same scan.

Conclusion: (18)F-fluoroestradiol uptake and the (18)F-fluoroestradiol/(18)F-FDG ratio varied greatly between patients but were usually consistent across lesions in the same scan. The average (18)F-fluoroestradiol SUV and (18)F-fluoroestradiol/(18)F-FDG ratio for a limited sample of lesions appear to provide a reasonable summary of synchronous ER expression for most patients. However, imaging the entire disease burden remains important to identify the subset of patients with mixed uptake, who may be at a critical point in their disease evolution.

Conflict of interest statement

No other potential conflict of interest relevant to this article was reported.

Figures

FIGURE 1

LBM-adjusted 18F-fluoroestradiol mean SUV (y-axis, log2 scale) for 505 lesions in each of 91 patients (x-axis, sorted by average 18F-fluoroestradiol SUV). Vertical points show within-patient heterogeneity. Horizontal line shows threshold of SUV = 1. FES = fluoroestradiol; LN = lymph node.

FIGURE 2

Torso survey images from 3 female patients with metastatic breast cancer from ER+/HER2-negative primary histology (patient in A had PgR-negative primary tumor histology; patients in B and C had PgR-positive). (A) (sagittal view; index 85 in Figs. 1, 3, and 4): 48-y-old with bone-dominant disease with high 18F-fluoroestradiol uptake and high 18F-FDG uptake. (B) (coronal view; index 13 in Figs. 1, 3, and 4): 62-y-old with uniformly low 18F-fluoroestradiol uptake on 18F-fluoroestradiol PET. Three soft-tissue lesions (18F-fluoroestradiol mean SUVLBM of 0.3, 0.5, and 0.7) are identified by arrows. (C) (sagittal view; index 32 in Figs. 1, 3, and 4): 52-y-old with spinal lesion visible on both 18F-fluoroestradiol PET images and 18F-FDG PET images and sternal lesion with visible 18F-FDG but negative 18F-fluoroestradiol PET. FES = fluoroestradiol.

FIGURE 3

LBM-adjusted 18F-FDG maximum SUV (y-axis, log2 scale) for 492 lesions in each of 89 patients (x-axis, sorted by average 18F-FDG SUV). FES = fluoroestradiol; LN = lymph node.

FIGURE 4

Ratio of 18F-fluoroestradiol maximum SUV and 18F-FDG maximum SUV (y-axis, square root scale) for 492 lesions in each of 89 patients (x-axis, sorted by average 18F-fluoroestradiol SUV). FES = fluoroestradiol; LN = lymph node.