Prediction of therapy response in bone-predominant metastatic breast cancer: comparison of [(18)F] fluorodeoxyglucose and [(18)F]-fluoride PET/CT with whole-body MRI with diffusion-weighted imaging

PURPOSE: To compare [(18)F]-fluorodeoxyglucose (FDG) and [(18)F]-sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) with whole-body magnetic resonance with diffusion-weighted imaging (WB-MRI), for endocrine therapy response prediction at 8 weeks in bone-predominant metastatic breast cancer. PATIENTS AND METHODS: Thirty-one patients scheduled for endocrine therapy had up to five bone metastases measured [FDG, NaF PET/CT: maximum standardized uptake value (SUV(max)); WB-MRI: median apparent diffusion coefficient (ADC(med))] at baseline and 8 weeks. To detect the flare phenomenon, a 12-week NaF PET/CT was also performed if 8-week SUV(max) increased. A 25% parameter change differentiated imaging progressive disease (PD) from non-PD and was compared to a 24-week clinical reference standard and progression-free survival (PFS). RESULTS: Twenty-two patients (median age, 58.6 years, range, 40–79 years) completing baseline and 8-week imaging were included in the final analysis. Per-patient % change in NaF SUV(max) predicted 24-week clinical PD with sensitivity, specificity and accuracy of 60, 73.3, and 70%, respectively. For FDG SUV(max) the results were 0, 100, and 76.2% and for ADC(med), 0, 100 and 72.2%, respectively. PFS < 24 weeks was associated with % change in SUV(max) (NaF: 41.7 vs. 0.7%, p = 0.039; FDG: − 4.8 vs. − 28.6%, p = 0.005) but not ADC(med) (− 0.5 vs. 10.1%, p = 0.098). Interlesional response heterogeneity occurred in all modalities and NaF flare occurred in seven patients. CONCLUSIONS: FDG PET/CT and WB-MRI best predicted clinical non-PD and both FDG and NaF PET/CT predicted PFS < 24 weeks. Lesional response heterogeneity occurs with all modalities and flare is common with NaF PET/CT.