Molecular imaging as biomarker for treatment response and outcome in breast cancer

Molecular imaging, such as positron emission tomography (PET), is increasingly used as biomarker to predict and assess treatment response in breast cancer. The number of biomarkers is expanding with specific tracers for tumour characteristics throughout the body and this information can be used to aid the decision-making process. These measurements include metabolic activity using [(18)F]fluorodeoxyglucose PET ([(18)F]FDG-PET), oestrogen receptor (ER) expression using 16α-[(18)F]Fluoro-17β-oestradiol ([(18)F]FES)-PET and human epidermal growth factor receptor 2 (HER2) expression using PET with radiolabelled trastuzumab (HER2-PET). In early breast cancer, baseline [(18)F]FDG-PET is frequently used for staging, but limited subtype-specific data reduce its usefulness as biomarker for treatment response or outcome. Early metabolic change on serial [(18)F]FDG-PET is increasingly used in the neo-adjuvant setting as dynamic biomarker to predict pathological complete response to systemic therapy, potentially allowing de-intensification or step-up intensification of treatment. In the metastatic setting, baseline [(18)F]FDG-PET and [(18)F]FES-PET can be used as biomarker to predict treatment response, in triple-negative and ER-positive breast cancer, respectively. Metabolic progression on repeated [(18)F]FDG-PET appears to precede progressive disease on standard evaluation imaging; however, subtype-specific studies are limited and more prospective data are needed before implementation in clinical practice. Even though (repeated) [(18)F]FDG-PET, [(18)F]FES-PET and HER2-PEt all show promising results as biomarkers to predict therapy response and outcome, for eventual integration into clinical practice, future studies will have to clarify at what timepoint this integration has to optimally take place.