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METABOLIC FLARE AFTER AN ESTRADIOL CHALLENGE
Authored By: Garima Agrawal and Farrokh Dehdashti.
Patient: 34 year old female
History: 34 year old woman with metastatic breast cancer status post right mastectomy and right axillary lymph node
dissection along with chemoradiation.
Image Size:[small][as-submitted]

Multimedia: 347823_1_submitted.avi
Baseline PET/CT

Multimedia: 347823_2_submitted.avi
PET/CT 2 days later

Fig. 3
Liver lesion

Fig. 4
Neck

Fig. 5
T9 thoracic vertebrae

Fig. 6
T12 thoracic vertebrae
Image Size:[small][as-submitted]

Findings:

Almost all of the hypermetabolic lesions seen on previous study demonstrate increased FDG uptake on later study. Multiple small hypermetabolic liver lesions are only seen on the later study except for one of the lesion that was seen in retrospect on previous study.

Maximum standardized uptake values (SUV max) were computed for the
following osseous lesions:

LESION: SUVmax (baseline or initial)/SUVmax (post-estradiol)

Right cervical level 2 lymph node: 11.52 / 12.91
T6: 5.9/8.2
T9: 6.8/11.3
T12: 8.4/ 8.8
L1: 9.5/11
Right iliac bone: 9.8/10.4

The average maximum SUV for the baseline study was 6.9 and the average
maximal SUV of the post-estradiol study was 10.4. The estradiol challenge
resulted in an 51% increase in average maximum SUV.

DDx:
  1. Estradiol Flare reaction
  2. Worsening disease
Diagnosis: Metabolic Flare after an estradiol challenge
General Discussion:

This is a 34 year old patient with estrogen receptor (ER) positive, progesterone receptor (PR) positive, Her-2 neu negative stage IV breast cancer metastatic to bone.  The later study or post-estradiol study was performed to compare with the most recent prior study after estradiol  challenge to evaluate for a metabolic flare. Three doses of estradiol (total of 6 mg) were taken by the patient, with the last dose taken 1 hour prior to this PET study. Initial study served as baseline study.

The ER positive breast cancer patient are potential candidates for endocrine therapy. However, the presence of these hormones predict clinical benefit in only a small percentage of patients with advanced disease. And hence development of a clinical or metabolic flare reaction after initiation of endocrine therapy is more accurate to predict the patient who would benefit from treatment. PET findings have been shown to be predictive of response to treatment with tamoxifen in woman with advanced ER+ breast cancer. Additionaly, metabolic flare on FDG-PET is shown to be a marker for activation of estrogen signaling and implies that ER is functional. It has been prospectively investigated that an increase in tumor standardized uptake value of 12% or greater is defined as the threshold for a positive estradiol stimulation test. Metabolic flare on FDG-PET can be seen within 24 hours of initiating treatment and is predictive of benefit from endocrine therapy.

 

References:
  1. Mortimer JE, Dehdashti F, Siegel BA, Trinkaus K, Katzenellenbogen JA, Welch MJ. Metabolic flare: indicator of hormone responsiveness in advanced breast cancer. J Clin Oncol. 2001 Jun 1;19(11):2797-803.
  2. Dehdashti F, Mortimer JE, Trinkaus K, Naughton MJ, Ellis M, Katzenellenbogen JA, Welch MJ, Siegel BA. PET-based estradiol challenge as a predictive biomarker of response to endocrine therapy in women with estrogen-receptor-positive breast cancer. Breast Cancer Res Treat. 2009 Feb;113(3):509-17. Epub 2008 Mar 9.
  3. Ellis MJ, Gao F, Dehdashti F, Jeffe DB, Marcom PK, Carey LA, Dickler MN, Silverman P, Fleming GF, Kommareddy A, Jamalabadi-Majidi S, Crowder R, Siegel BA. Lower-dose vs high-dose oral estradiol therapy of hormone receptor-positive, aromatase inhibitor-resistant advanced breast cancer: a phase 2 randomized study. JAMA. 2009 Aug 19;302(7):774-80.
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Additional Details:

Case Number: 347823Owner(s): Garima Agrawal and Farrokh DehdashtiLast Updated: 12-07-2011
Anatomy: Breast   Pathology: Neoplasm
Modality: PETAccess Level: Readable by all users, writable by NucMed Certifiers
Keywords: ptnm, estradiol, flare

Case has been viewed 14 times.
Certified by Farrokh Dehdashti on 11-08-2011

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