众所周知，肿瘤细胞主要通过摄取葡萄糖获取能量。因此，肿瘤组织与正常组织相比，葡萄糖浓度显著较高。将第2位氧原子被原子量为18的氟同位素取代的氟代脱氧葡萄糖18F-FDG注入体内，可以通过正电子发射断层扫描/X线计算机断层成像PET/CT精准显示全身早期肿瘤大小和部位。
2019年12月11日，美国转化肿瘤学会《肿瘤学家》在线发表复旦大学附属肿瘤医院邬思雨、王玉洁、李剑伟、张娜、邵志敏、程竞仪、柳光宇等学者的研究报告，探讨了18F-FDG PET/CT对于预测淋巴结阳性早期乳腺癌术前新辅助化疗患者术后腋窝淋巴结缓解、指导个体化腋窝手术的价值和可行性。
该单中心前瞻研究于2014～2018年从复旦大学附属肿瘤医院入组133例经活检证实为淋巴结转移的早期乳腺癌患者。术前新辅助化疗±曲妥珠单抗治疗之前进行18F-FDG PET/CT扫描，对于111例最大标准摄取值与全身平均摄取值之比SUVmax≥2.5的患者，两轮术前新辅助化疗后进行第二次扫描，并对其中SUVmax仍然 ≥ 2.5的81例患者进行靶向腋窝清扫，再对全部患者进行腋窝淋巴结清扫。通过与最终病理结果进行比较，计算准确性。
结果发现，第一次18F-FDG PET/CT扫描SUVmax ≥ 2.5且两次相差 ≥ 78.4%为最佳临界值，预测腋窝病理完全缓解的真阳性率达79.0%、真阴性率达71.4%、真阳性率与真阴性率的曲线下面积达0.75（95%置信区间：0.65～0.84）。
初步亚组分析表明，对于雌激素受体阴性、HER2阳性患者，预测腋窝病理完全缓解的价值不大（曲线下面积：0.55，真阳性率：56.5%，真阴性率：50.0%）。
采用18F-FDG PET/CT，可以避免19例患者进行补充的二次腋窝淋巴结清扫，并且对于其余非雌激素受体阴性、HER2阳性亚型患者，可以减少1/3例靶向腋窝清扫假阴性病例。
因此，该研究结果表明，18F-FDG PET/CT可以准确预测淋巴结阳性乳腺癌患者术前新辅助化疗后的淋巴结缓解状态，并且有助于个体化实施腋窝手术，包括确定哪些患者适合进行靶向腋窝清扫，或者适合直接进行腋窝淋巴结清扫。该方法可能有助于减少靶向腋窝清扫的假阴性病例。
Oncologist. 2019 Dec 11. [Epub ahead of print]
Subtype-Guided 18F-FDG PET/CT in Tailoring Axillary Surgery Among Patients with Node-Positive Breast Cancer Treated with Neoadjuvant Chemotherapy: A Feasibility Study.
Wu S, Wang Y, Li J, Zhang N, Mo M, Klimberg S, Kaklamani V, Cochet A, Shao Z, Cheng J, Liu G.
Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China; Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; University of Texas Medical Branch Galveston, Texas, USA; Northwestern University, Chicago, Illinois, USA; Centre Georges-Francois Leclerc, University Hospital of Dijon, Dijon, France.
BACKGROUND: The purpose of this study was to investigate the value of 18[F]-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) in tailoring axillary surgery by predicting nodal response among patients with node-positive breast cancer after neoadjuvant chemotherapy (NAC).
METHODS: One hundred thirty-three patients with breast cancer with biopsy-confirmed nodal metastasis were prospectively enrolled. 18F-FDG PET/CT scan was performed before NAC (a second one after two cycles with baseline maximum standardized uptake value [SUVmax] ≥2.5), and a subset of patients underwent targeted axillary dissection (TAD). All the patients underwent axillary lymph node dissection (ALND). The accuracy was calculated by a comparison with the final pathologic results.
RESULTS: With the cutoff value of 2.5 for baseline SUVmax and 78.4% for change in SUVmax, sequential 18F-FDG PET/CT scans demonstrated a sensitivity of 79.0% and specificity of 71.4% in predicting axillary pathologic complete response with an area under curve (AUC) of 0.75 (95% confidence interval, 0.65-0.84). Explorative subgroup analyses indicated little value for estrogen receptor (ER)-negative, human epidermal growth factor receptor 2 (HER2)-positive patients (AUC, 0.55; sensitivity, 56.5%; specificity, 50.0%). Application of 18F-FDG PET/CT could spare 19 patients from supplementary ALNDs and reduce one of three false-negative cases in TAD among the remaining patients without ER-negative/HER2-positive subtype.
CONCLUSION: Application of the subtype-guided 18F-FDG PET/CT could accurately predict nodal response and aid in tailoring axillary surgery among patients with node-positive breast cancer after NAC, which includes identifying candidates appropriate for TAD or directly proceeding to ALND. This approach might help to avoid false-negative events in TAD.
IMPLICATIONS FOR PRACTICE: This feasibility study showed that 18[F]-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) could accurately predict nodal response after neoadjuvant chemotherapy (NAC) among patients with breast cancer with initial nodal metastasis except in estrogen receptor-negative, human epidermal growth factor receptor 2-positive subtype. Furthermore, the incorporation of 18F-FDG PET/CT can tailor subsequent axillary surgery by identifying patients with residual nodal disease, thus sparing those patients supplementary axillary lymph node dissection. Finally, we have proposed a possibly feasible flowchart involving 18F-FDG PET/CT that might be applied in post-NAC axillary evaluation.
KEYWORDS: Subtype-guided; 18[F]-fluorodeoxyglucose positron emission tomography/computed tomography; Response; Axillary surgery; Neoadjuvant chemotherapy
PMID: 31826976
DOI: 10.1634/theoncologist.2019-0583
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