Abstract OT2-01-01: Trial in Progress: Clinical Utility of Fluoroestradiol F18 PET/CT in Metastatic Breast Cancer Patients with ER-Positive and HER2-Negative Primary Lesions after Progression on First Line Hormonal Therapy
Authors: van de Ven Stephanie , Luo Feng , DiGregorio Nicholas , Fuentes-Alburo Adolfo , Tranquart Francois 
Published: March 2023

BACKGROUND: Cyclin-dependent kinase 4/6 (CDK4/6) inhibitors combined with endocrine therapy are the recommended first-line standard-of-care (SOC) treatment for estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative metastatic breast cancer (MBC) patients. After progression on first-line treatment, current clinical practice guidelines (NCCN, ESMO) recommend to sequence endocrine therapy (in absence of visceral crisis) until there is no clinical benefit after up to 3 regimens, and subsequently initiate chemotherapy regimens. However, clinical benefit for endocrine monotherapy after progression on first-line standard-of-care is limited, with median progression-free survival (PFS) of 2-5 months. Multiple factors can contribute to endocrine therapy resistance, including changes in ER expression, (epi)genetic mutations, and/or clonal selection under therapeutic pressure. ER heterogeneity can occur over time (temporal) as well as between lesions in a patient (spatial). As confirmed by tissue biopsy, greater than 20% of MBC patients have discordance in ER expression between their primary tumor and a metastatic lesion. Measuring total ER heterogeneity in a patient – the variation in ER expression at whole body level across all MBC lesions – is not clinically feasible by tissue biopsy alone. Fluoroestradiol F18 (Cerianna), also called 18F-FES, is a radioactive diagnostic agent that can be used with PET/CT for in vivo detection of ER-positive lesions in MBC with high accuracy. Results from 18F-FES PET/CT studies have shown that ER expression across MBC lesions at whole body level is heterogeneous in approximately half of ER-positive, HER2-negative MBC patients. In this study, we aim to evaluate the clinical utility of 18F-FES PET/CT to guide second-line treatment decision in ER-positive, HER2-negative MBC patients with progressive disease on first-line SOC hormonal therapy. METHODS: Fluoroestradiol F18 (Cerianna) is being evaluated in a phase 4, open-label, prospective cohort study enrolling 206 patients at 20-30 centers in the United States. Patients diagnosed with ER-positive, HER2-negative MBC who have progressive disease on first-line aromatase inhibitor therapy with or without CDK4/6 inhibitor will be included in the study; patients with isolated hepatic metastases will be excluded. All patients will undergo an 18F-FES PET/CT scan. The treating physician will complete a standardized questionnaire to indicate the second-line therapeutic management plan before the scheduled 18F-FES PET/CT. After interpretation of 18F-FES PET/CT by local radiologist or nuclear medicine physician, imaging results will be provided to the treating physician who will then fill out a similar questionnaire to specify the final therapeutic decision. The proportion of patients with a change in therapeutic management plan based on incorporation of 18F-FES PET/CT results will be the primary endpoint. During the study follow-up period of 18 months, data on SOC imaging, treatments/procedures received, and clinical outcomes will be collected. Secondary endpoints include visual and quantitative heterogeneity assessment of tumor 18F-FES uptake, and PFS rates at 6 months and 18 months after 18F-FES PET/CT, which will be assessed between patients with and without a change in therapeutic management plan. The trial is planned to begin enrollment in Q3 2022. Clinical trial information: NCT05068726

Citation Format: Stephanie van de Ven, Feng Luo, Nicholas DiGregorio, Adolfo Fuentes-Alburo, Francois Tranquart. Trial in Progress: Clinical Utility of Fluoroestradiol F18 PET/CT in Metastatic Breast Cancer Patients with ER-Positive and HER2-Negative Primary Lesions after Progression on First Line Hormonal Therapy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT2-01-01.