PET Imaging in Metastatic Breast Cancer

Outline
Locoregional Staging
the Axilla
Accuracy of Axillary Ultrasound
MRI of Axillary Nodes
MRI of Axillary Nodes
Axillary Node Detection by PET/CT
PET/CT for Regional Node Evaluation Prior
to NAC
Internal Mammary Nodes
Left Inflammatory Cancer With Bilateral
Axillary and IM Adenopathy
At What Stage Should
We Do Systemic Staging?
Clinical Stage II and III
Upstaging:
MSKCC
Upstaging:
Triple-Negative Breast Cancer
Triple-Negative IIB Patients
Why Not Just Stage Patients With CT and Bone Scan?
Physiology Trumps Anatomy
PET/CT vs CT Alone
PET/CT vs CT and Bone Scan
163 Women With Suspected MBC
Undergoing PET/CT and BSc Within 30 days
Soft Tissue Metastases
Locally Recurrent Disease
Rising Tumor Markers
Exceptions/New Tracers
Invasive Lobular Carcinoma
ILC and Bone Mets
Invasive Lobular Cancer
 F-FACBC PET/CT: Newly Diagnosed
18

Cancer
ILC More FACBC Avid Than FDG
FES
MRI Suspicion of Metastases
FES and FDG PET/CT Can Predict PFS in
Patients With ER-Positive Breast Cancer on
Endocrine Therapy
68
Ga-FAPI PET/CT
 Ga-FAPI PET/CT vs 18FDG/PET Scan in
68

Breast Cancer
Detection of HER2-Positive Metastases with
HER2-Negative Primary Cancer
Detection of HER2-Postivie Gastric Cancer
Monitoring Afatinib Therapy
Response Assessment
PET/CT Monitoring Response to NAC
FDG PET/CT in NAC:
What is the Optimal Drop in SUV?
RECIST vs PERSIST
Bone Metastasis
Expert Opinion
Heterogeneous Response
Heterogeneous Response
68
Ga-FAPI PET/CT in Detecting Additional
Lesions vs
18
FDG PET/CT
Conclusions
Novel Strategies for Breast Cancer Assessment
and Response
Message
Lecture Outline
Lecture Outline
Does This Patient Have Locally Advanced
Breast Cancer?
Does This Patient Have Locally Advanced
Breast Cancer?
Locally Advanced Breast Cancer
MR Imaging for Initial Staging
Expert Opinion
How Is Breast MRI Performed?
MR More Accurate for Extent of Disease
Patient With Newly Diagnosed ILC
Invasive Lobular CA:
Newly Diagnosed, Baseline MRI
Invasive Lobular CA:
Newly Diagnosed, Baseline MRI
What Is the Most Appropriate BI-RADS
Assessment?
What Is the Most Appropriate BI-RADS
Assessment?
Breast MR BI-RADS Assessment in Setting
of NACT
Axillary Nodes on Breast MRI
Expert Opinion
Internal Mammary (IM) Nodes on Breast
MRI
Abnormal IM Node in Cancer Patient
Normal IM Node (Screening MRI)
CASE EXAMPLE:
Baseline MRI:
Left Axillary Adenopathy
Baseline MRI:
Locally Advanced Left Breast Cancer
Baseline MRI:
Left Internal Mammary Node
Baseline PET-CT:
Left Internal Mammary Node
CASE EXAMPLE
Improvement After NACT But Still
Significant Abnormal Enhancement
Case Example
Potential Problem for Myocutaneous Flap
Reconstruction
Lecture Outline
Response to NACT
Response to NACT
Lecture Outline
How Well Can MR Predict Response to
NACT?
ACRIN 6657/I-SPY Trial
The I-SPY Trial
The I-SPY Trial
Functional Tumor Volume Measurement
MR for Predicting Pathologic Response
MR Prediction of pCR After NACT
How Well Can MR Predict Recurrence-Free
Survival?
MR for Predicting RFS
MR for Predicting RFS: ACRIN 6657
MR for Predicting RFS: ACRIN 6657
I-SPY 2 Trial:
A Learning Model for Imaging Biomarker Development
I-SPY 2 and ACRIN 6698 Trials
DWI for Predicting Response (I-SPY2)
Diffusion-Weighted MR Imaging
Breast DWI vs ADC (Inverse Contrast)
Time Course of Tumor ADC Response
During Rx in
I-SPY2 Patients (n = 242)
Patient With pCR:
54-Year-Old Triple-Negative Breast
Cancer
ACRIN 6698 DWI Multi-Center Trial
For Further Reading
Lecture Outline
Dedicated Breast PET
Intratumoral Heterogeneity Brought Out by
Increased
Spatial Resolution of dbPET
Integration of dbPET Into I-SPY Schema for
Evaluation of Early Response to NAC
Early Results:
Breast MRI and dbPET (FDG)
Examples of FES Uptake in > 90% ER-
Positive/
HER2-Negative ILC and IDC (4 different
patients)
Beware of Positioning Differences:
PET/CT (Supine) vs MRI (Prone)
Lecture Outline
Message
FES and FDG PET in ILC and IDC
FDG PET/CT for Breast Cancer
T Staging With FDG PET/CT:
Poor Sensitivity and Specificity Compared With Other Imaging
N Staging (Axillary) With FDG PET/CT:
Poor Sensitivity but Good Specificity Compared With Sentinel
Node
N Staging (Extra-Axillary) With FDG PET/CT:
Good Sensitivity and Specificity
M Staging With FDG PET/CT:
Excellent Sensitivity and Specificity Compared With CT/Bone
Scan
In Advanced Local Breast Cancer
FDG PET/CT Improves Detection of Distant Metastases
FDG PET: TNM Staging
FDG PET: Where Is the Clinical Impact?
FDG PET/CT for Breast Cancer
Primary Tumor Response
Metastatic Tumor Response:
Substantial Patient Impact
Comparison of FDG PET/CT vs CECT for
Prediction of Survival in Patients With Stage
4 Breast Cancer
Impact of FDG PET Imaging for Expanding
Patient Eligibility and Measuring Treatment
Response in a Genome-Driven Basket Trial
Detection of Recurrent Disease:
FDG PET/CT > CT and Bone Scan
FDG PET:
Where Is the Clinical Impact?
FDG PET/CT for Breast Cancer
ILC: More Often Non-FDG
Avid Sclerotic Bone Metastases
FDG PET: Where Is the Clinical Impact?
Molecular Imaging and Therapy
Estrogen Receptor-Targeted Imaging With
FES
FES PET
SNMMI Appropriate Use Criteria for FES
PET
SNMMI Appropriate Use Criteria for FES
PET
Fluoroestradiol F-18 PET Predicts Response
of ER-Positive Breast Cancer to Endocrine
Therapy
Fluoroestradiol F-18 PET Predicts Response
of ER-Positive Breast Cancer to Endocrine
Therapy
Fluoroestradiol F-18 PET Predicts Response
of ER-Positive Breast Cancer to Endocrine
Therapy
Patient: Metastatic ER-Positive Breast Cancer
Progressing on First-Line ER-Targeted Therapy. Should Second-Line ER-Targeted Therapy Be
Used?
SNMMI Appropriate Use Criteria for FES
PET
Fluoroestradiol F-18 May Evaluate ER Status in Lesions
Difficult to Biopsy
SNMMI Appropriate Use Criteria for FES
PET
Fluoroestradiol F-18 May Be Used to Solve
Clinical Dilemmas in Recurrent or MBC
Cases
Fluoroestradiol F-18 PET/CT Trial at Hoag
(NCT04883814)
FES May Detect Metastatic ILC Better Than
FDG
FES Can Help Detect Dosage of Novel ER-
Targeted Therapies in Phase I Clinical Trials
FES Can Help Detect Dosage of Novel ER-
Targeted Therapies in Phase I Clinical Trials
How Artificial Intelligence Is Changing
Breast Imaging
The Global AI in Healthcare Market
was USD 10.4 B in 2021
Clinical Trials Segment Dominated AI
in the Healthcare Market in 2021
Objectives
FDA Classification of CAD Devices
Artificial Intelligence for Mammography
and Digital Breast Tomosynthesis
Gartner Hype Cycle CAD for Mammography
Gartner Hype Cycle CAD for Mammography
Clinical Value of AI Tools in Medical
Imaging
Detection
Characterization
Determine Prognosis or Response to
Treatment
The Digital Mammography DREAM
Challenge
The Digital Mammography DREAM
Challenge
Focusing on Benchmark of High NPV
DL-Triaged Workflow
Improved CDR with AI, Without Requiring
Additional Reading Time
External Validation of AI Systems
DL Algorithm Identifies Highlights the
Most Suspicious Area
Collective Intelligence
Improving Radiologists’ Performance
Interobserver Variability
ROC Curves With and Without AI CAD
ROC Curves With and Without AI CAD
AI Solutions for DBT
End to End DBT Classification Algorithm
End to End DBT Classification Algorithm
End to End DBT Classification Algorithm
Multiple Potential Opportunities for AI to
Enhance Benefits of Screening DBT Within
the Breast Imaging Value Chain
Take Home Points for AI and DBT
Breast Ultrasound - Should We Ignore,
Follow, or Biopsy?
Artificial Intelligence System Reduces False-
Positive Findings in the Interpretation of
Breast Ultrasound Exams[a]
External Validation with Egyptian Dataset
Triage Breast US to Reallocate Radiologists’
Time
Towards Exams with High Suspicion of
Malignancy
Results
Results
What Do Women Think About AI in
Mammography?
AI Imaging Value Chain
Radiology Value Chain
Added Value of AI Tools in Medical Imaging
THANK YOU
Precision Medicine and Radiogenomics:
Precision Medicine
Precision Medicine
Integrating Information
Rise of Artificial Intelligence Medicine
AI-Enhanced Breast Imaging
AI Applications Categories
AI Applications Categories
AI Applications Categories
AI Applications Categories
DWI DL Reconstruction
DWI DL Reconstruction
"Old" AI
Hand-Crafted Radiomics/Radiogenomics
New "AI"
Use Cases: Narrow AI
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Mammography:
Use Case Screening
AI-Enhanced Ultrasound: Use Case
Classification
Expert Opinion
AI-Enhanced Ultrasound
Use Case Classification
AI-Enhanced Ultrasound
Use Case Classification
AI-Enhanced Ultrasound
Use Case Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Classification
AI-Enhanced PET/MRI
Use Case: Classification
AI-Enhanced MRI
Use Case: Molecular Subtyping With DCE
AI-Enhanced CEM
Use Case: Molecular Subtyping
AI-Enhanced CEM
Use Case: Molecular Subtyping
AI-Enhanced MRI
Use Case: Molecular Subtyping with DWI
AI-Enhanced MRI
Use Case: Molecular Subtyping with mpMRI
AI-Enhanced MRI
Use Case: MRI Phenotypes and Tumor Gene
Expression
AI-Enhanced MRI
Use Case: MRI Phenotypes and Tumor Gene
Expression
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Treatment Response
AI-Enhanced MRI
Use Case: Recurrence Scores With DCE-MRI
AI-Enhanced MRI
Use Case: Recurrence Scores With DCE-MRI
AI-Enhanced MRI
Use Case: Recurrence Scores With DCE-MRI
AI-Enhanced MRI
Use Case: Recurrence Scores With DCE-MRI
AI-Enhanced Mammography
Use Case: Risk Assessment
AI-Enhanced MRI
Use Case: Risk Assessment
AI-Enhanced MRI
Use Case: Risk Assessment
Summary
Challenges for AI-Enhanced Medicine
Implementation of AI in Breast Imaging