Value of (18)F-FDG PET/CT for predicting axillary pathologic complete response following neoadjuvant systemic therapy in breast cancer patients: emphasis on breast cancer subtype

BACKGROUND: Neoadjuvant systemic therapy (NST) is a widely accepted initial treatment modality that can lead to pathologic downstaging of the axillary disease burden in breast cancer patients. Axillary response as well as baseline (18)F-fluorodeoxyglucose ((18)F-FDG) uptake on positron emission tomography with computed tomography (PET/CT) differ between breast cancer subtypes. The value of baseline (18)F-FDG PET/CT in predicting axillary response to NST is not yet established, possibly since breast cancer subtype was not taken into account. The purpose of this study was to investigate the value of baseline (18)F-FDG PET/CT in predicting axillary response to NST with a specific emphasis on subtype. METHODS: PET-parameters derived from the primary tumor as well as the most FDG-avid axillary lymph node were measured on baseline (18)F-FDG PET/CT. Overall imaging findings were compared with the gold standard of histopathology of the axillary surgery specimen. Analyses for ER-positive/HER2-negative were performed separately from HER2-positive and TN patients. In addition, separate analyses for clinically node-positive patients were performed. RESULTS: Sixty-six patients with 69 primary tumors were included in this study. Thirty-three axillae contained ER-positive/HER2-negative, 16 HER2-positive, and 20 TN breast cancer. No significant difference in PET-parameters between patients with axillary residual disease and axillary pathologic complete response were found for ER-positive/HER2-negative breast cancer. In the combined HER2-positive/TN subgroup, the SUV(max) was significantly lower in patients without residual axillary disease in both the entire cohort and in patients with clinically node-positive disease. In this combined subgroup, a cut-off of 4.89 SUV(max) measured on the most FDG-avid axillary lymph node could predict residual axillary disease with a sensitivity, specificity, PPV, and NPV of 90%, 69%, 53%, and 95%, respectively. CONCLUSIONS: Predicting axillary response following NST with baseline (18)F-FDG PET/CT can be performed when focusing on breast cancer subtypes. The easily computed PET-parameter SUV(max) can predict axillary response in HER2-positive and TN breast cancer. This study adds to the accumulating evidence that studies investigating the value of (18)F-FDG PET/CT in breast cancer should always take subtypes into account. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13550-021-00861-z.