Preoperative 18[F]-fluorodeoxyglucose positron emission tomography/computed tomography predicts early recurrence after pancreatic cancer resection. Int J Clin Oncol. 2011;16:39-44. [PMID: 20862596 DOI: 10.1007/s10147-010-0124-z]

The role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography-derived parameters as prognostic factors in patients undergoing resection for pancreatic ductal adenocarcinoma

BACKGROUND

The aim of this study is to investigate the role of maximum standardized uptake and tumor-to-liver ratio derived from preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography in patients with pancreatic ductal adenocarcinoma.

METHODS

Patients who underwent pancreatic resection from January 2015 to December 2022 were reviewed. Patients were grouped based on disease-free survival of 1 year, disease-free survival of 6 months, overall survival of 1 year, and resectability.

RESULTS

A total of 133 patients were included in the study. The median maximum standardized uptake was significantly greater in patients with shorter survival than in those with longer survival (disease-free survival <1 year vs >1 year: 7.1 [4.3-9.1] vs 4.9 [3.3-6.5], P < .001; disease-free survival <6 months vs >6 months: 8 [4.5-9.7] vs 5.2 [3.4-6.8], P = .001; overall survival <1 year vs >1 year: 6.9 [4.4-8.8] vs 5 [3.4-6.9], P = .01). Median maximum standardized uptake was significantly greater in patients with intraoperative findings of unresectable disease than in those who underwent surgical resection (7.4 [5.5-9.5] vs 5.5 [3.8-7.8], P = .02). These findings were consistent for tumor-to-liver ratio for all groupings. The area under the curve based on receiver operating characteristic analysis was 0.7 for both maximum standardized uptake and tumor-to-liver ratio for predicting disease-free survival, overall survival, and resectability.

CONCLUSION

Preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography maximum standardized uptake and tumor-to-liver ratio are indicators of resectability, early recurrence, and poor prognosis in patients with pancreatic ductal adenocarcinoma. A maximum standardized uptake value between 5 and 7 is a potential red flag, and further investigations should be considered before proceeding to a pancreatic resection.

Early Recurrence After Resection of Locally Advanced Pancreatic Cancer Following Induction Therapy: An International Multicenter Study

OBJECTIVE

To establish an evidence-based cutoff and predictors for early recurrence in patients with resected locally advanced pancreatic cancer (LAPC).

BACKGROUND

It is unclear how many and which patients develop early recurrence after LAPC resection. Surgery in these patients is probably of little benefit.

METHODS

We analyzed all consecutive patients undergoing resection of LAPC after induction chemotherapy who were included in prospective databases in The Netherlands (2015-2019) and the Johns Hopkins Hospital (2016-2018). The optimal definition for "early recurrence" was determined by the post-recurrence survival (PRS). Patients were compared for overall survival (OS). Predictors for early recurrence were evaluated using logistic regression analysis.

RESULTS

Overall, 168 patients were included. After a median follow-up of 28 months, recurrence was observed in 118 patients (70.2%). The optimal cutoff for recurrence-free survival to differentiate between early (n=52) and late recurrence (n=66) was 6 months ( P <0.001). OS was 8.4 months [95% confidence interval (CI): 7.3-9.6] in the early recurrence group (n=52) versus 31.1 months (95% CI: 25.7-36.4) in the late/no recurrence group (n=116) ( P <0.001). A preoperative predictor for early recurrence was postinduction therapy carbohydrate antigen (CA) 19-9≥100 U/mL [odds ratio (OR)=4.15, 95% CI: 1.75-9.84, P =0.001]. Postoperative predictors were poor tumor differentiation (OR=4.67, 95% CI: 1.83-11.90, P =0.001) and no adjuvant chemotherapy (OR=6.04, 95% CI: 2.43-16.55, P <0.001).

CONCLUSIONS

Early recurrence was observed in one third of patients after LAPC resection and was associated with poor survival. Patients with post-induction therapy CA 19-9 ≥100 U/mL, poor tumor differentiation and no adjuvant therapy were especially at risk. This information is valuable for patient counseling before and after resection of LAPC.

The Impact of Metabolic 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Parameters on the Prognosis of Resectable Pancreatic Adenocarcinoma

Objectives

¹⁸F-fluorodeoxyglucose (FDG)-positron emission tomography/computed tomography (PET/CT) is a useful staging method in pancreatic cancer. The prognosis of pancreatic adenocarcinoma is affected by the tumor stage and resectable state. Maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) of primary tumors are related to prognostic parameters in pancreatic cancer. This study compared ¹⁸F-FDG PET/CT findings with prognostic factors and overall survival of patients with pancreatic cancer.

Methods

Patients with pancreatic adenocarcinoma, referred to our department between 2015 and 2022 for staging, were retrospectively evaluated. Head-to mid-thigh PET/CT images were obtained 1 h after ¹⁸F-FDG injection. Demographic data, survival, and clinical and pathological findings of 39 patients, who underwent surgery after PET/CT imaging, were collected. All primary tumor MTV, SUV_max, background SUV_max, and TLG data have were measured.

Results

The images of 39 patients (24 women and 15 men) with a mean age of 66.62±9.60 years were evaluated. The mean SUV_max, MTV 40%, and TLG of the primary tumors in the pancreatic tissue were 6.28±2.33, 19.33±9.77, and 66.56±45.99, respectively. The average survival after disease diagnosis was 18.97±11.47 (2-55) months. MTV and TLG were significantly higher in patients who died during our study. SUV_max has a significant effect on mortality.

Conclusion

¹⁸F-FDG PET/CT metabolic parameters of SUV_max, MTV, and TLG could help predicting the prognosis of pancreatic cancer preoperatively and follow-up in patients with resectable tumors. Additionally, in our study group tumor grade and perineural invasion significantly affected overall survival.

DUPAN-2 as a Risk Factor of Early Recurrence After Curative Pancreatectomy for Patients With Pancreatic Ductal Adenocarcinoma

OBJECTIVES

Several patients with pancreatic ductal adenocarcinoma (PDAC) experience postoperative early recurrence (ER). We evaluated PDAC patients to identify the risk factors for postoperative ER (≤6 months), including preoperative serum DUPAN-2 level.

METHODS

We retrospectively evaluated 74 PDAC patients who underwent pancreatectomy with curative intent. Clinicopathological factors including age, sex, body mass index, postoperative complications, pathological factors, preoperative C-reactive protein/albumin ratio, neutrophil/lymphocyte ratio, modified Glasgow prognostic score, preoperative tumor markers (carcinoembryonic antigen, carbohydrate antigen 19-9, SPAN-1, and DUPAN-2), and history of adjuvant chemotherapy were investigated. Early recurrence risk factors were determined using multivariate logistic regression analysis.

RESULTS

Recurrence and ER occurred in 52 (70.3%) and 23 (31.1%) patients, respectively. Univariate analysis revealed that postoperative complications, C-reactive protein/albumin ratio ≥0.02, neutrophil/lymphocyte ratio ≥3.01, carbohydrate antigen 19-9 ≥ 92.3 U/mL, SPAN-1 ≥ 69 U/mL, DUPAN-2 ≥ 200 U/mL, and absence of adjuvant chemotherapy were significant risk factors for ER. In multivariate analysis, DUPAN-2 ≥ 200 U/mL (P = 0.04) and absence of adjuvant chemotherapy (P = 0.02) were identified as independent risk factors for ER.

CONCLUSIONS

A higher level of preoperative DUPAN-2 was an independent risk factor for ER. For patients with high DUPAN-2 level, neoadjuvant therapies might be required to avoid ER.

Preoperative carbohydrate antigen 19-9 and standard uptake value of positron emission tomography-computed tomography as prognostic markers in patients with pancreatic ductal adenocarcinoma

BACKGROUND

Among various prognostic factors of pancreatic cancer, preoperative clinical information is obtained by imaging modality. This study aimed to evaluate clinical usefulness of preoperative carbohydrate antigen and preoperative standard uptake value in 18F-fluorodeoxyglucose positron emission tomography as predictive biological markers for resectable pancreatic ductal adenocarcinoma.

METHODS

A total of 189 patients with PDAC who underwent preoperative PET-computed tomography were evaluated. Patients underwent neoadjuvant chemotherapy, and R2 resection was excluded. The correlation between SUVmax and clinicopathologic parameters was analyzed. The C-tree statistical method was used to estimate cutoff values of logCA19-9 and SUVmax for survival rate. A multivariate analysis was conducted to identify prognostic factors for overall survival.

RESULTS

The median duration of OS was 26 months, and the 5-year survival rate was 22.4%. The optimal cutoff values for CA19-9 level was 150 U/mL and SUVmax was 5.5. When subjects were divided into three groups according to the combination of CA19-9 level and SUVmax from C-tree (high-risk group, CA19-9 > 150 U/mL and SUVmax > 5.5; intermediate-risk group, CA19-9 ≤ 150 U/mL and SUVmax > 5.5 or CA19-9 > 150 U/mL and SUVmax ≤ 5.5; and low-risk group, CA19-9 ≤ 150 U/mL and SUVmax ≤ 5.5), there was a significant 5YSR difference (5.6%, 24.3%, and 36.5%, P < .001). The multivariate analysis revealed high SUVmax, high preoperative CA19-9 level, venous invasion, and adjuvant chemotherapy were prognostic factors of OS.

CONCLUSIONS

CA19-9 and SUVmax are strong prognostic biological factors in resectable PDAC. Moreover, patients with high CA19-9 level and SUVmax are not indicated for upfront surgery.

High SUVmax on routine pre-operative FDG-PET predicts early recurrence in pancreatic and peri-ampullary cancer

BACKGROUND

SUVmax of a primary pancreatic tumour on FDG-PET/CT (SUVmax-p) may predict early post-operative recurrence. This has not been tested in the context of routine pre-operative FDG-PET/CT. It is also unknown whether this association exists independent of local residual tumour.

METHODS

FDG-PET/CT was performed routinely prior to resection of pancreatic or peri-ampullary adenocarcinoma between 2008 and 2012 as part of a previous prospective study. We compared SUVmax-p according to whether recurrence was diagnosed within 6 months of resection. We also determined the odds ratio for recurrence within 6 months for multiple cut-points of SUVmax-p. This analysis was repeated exclusively for patients who had resection with clear surgical margins (R0).

RESULTS

Of 56 patients from the initial study 23 underwent resection and were eligible. Recurrence within 6 months was associated with higher median SUVmax-p (5.9 vs 3.5; p = 0.04). This was also observed in 12 patients who underwent R0 resection (6.5 vs 2.2; p = 0.05). The cut-point with the highest odds for recurrence within 6 months for both groups was SUVmax-p ≥ 5.5 (OR = 10.8, CI = 1.56-109; OR[R0] = 24.0, CI = 1.64-1020).

CONCLUSION

SUVmax-p on routine FDG-PET/CT is useful for identifying patients likely to benefit from additional pre-operative staging or neoadjuvant therapy, even where clear margins can confidently be achieved.

Clinical Impact of Dual Time Point 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Fusion Imaging in Pancreatic Cancer

We examined the value of preoperative dual time point (DTP) 18F-fluorodeoxyglucose positron emission tomography/computed tomography fusion imaging (FDG PET/CT) as a predictor of early recurrence or the outcomes in patients with pancreatic cancer. Standardized uptake values (SUVs) in DTP FDG PET/CT were performed as preoperative staging. SUVmax1 and SUVmax2 were obtained in 60 min and 120 min, respectively. ΔSUVmax% was defined as (SUVmax2 − SUVmax1)/SUVmax1 × 100. The optimal cut-off values for SUVmax parameters were selected based on tumor relapse within 1 year of surgery. Optimal cut-off values for SUVmax1 and ΔSUVmax% were 7.18 and 24.25, respectively. The combination of SUVmax1 and ΔSUVmax% showed higher specificity and sensitivity, and higher positive and negative predictive values for tumor relapse within 1 year than SUVmax1 alone. Relapse-free survival (RFS) was significantly worse in the subgroups of high SUVmax1 and high ΔSUVmax% (median 7.0 months) than in the other subgroups (p < 0.0001). The multivariate Cox analysis of RFS identified high SUVmax1 and high ΔSUVmax% as independent prognostic factors (p = 0.0060). DTP FDG PET/CT may effectively predict relapse in patients with pancreatic cancer. The combination of SUVmax1 and ΔSUVmax% identified early recurrent patient groups more precisely than SUVmax1 alone.

18F-Fluorodeoxyglucose-PET-Computerized Tomography and non-Fluorodeoxyglucose PET-Computerized Tomography in Hepatobiliary and Pancreatic Malignancies

Molecular imaging with PET-computerized tomography (PET-CT) plays an important role in oncology. There is current and evolving evidence supporting the use of fluorodeoxyglucose (FDG) and non-FDG tracers in assessment patients with hepatobiliary and pancreatic cancers in various clinical scenarios. In this chapter, we discuss the advantages and limitations of FDG and non-FDG PET-CT in the management of patients with hepatobiliary and pancreatic cancers.

Prediction of pathological response to preoperative chemotherapy for pancreatic ductal adenocarcinoma using 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography

AIM

To determine whether the pathological response to preoperative chemotherapy for pancreatic ductal adenocarcinoma (PDAC) can be predicted using 2-[18F]-fluoro-2-deoxy-d-glucose positron-emission tomography (F-18 FDG-PET).

MATERIALS AND METHODS

Twenty-eight patients with PDAC who underwent only neoadjuvant chemotherapy (NAC) before surgery were enrolled in the study. All patients had F-18 FDG-PET examinations before NAC. The resected specimen was pathologically evaluated according to the Classification of Pancreatic Carcinoma (7th edn). Patients were categorised into a non-response group and a response group based on the pathological findings. The non-response group (Grades 1a and 1b) showed ≤50% necrosis in the specimen, while the specimens of the response group (Grades 2-3) showed >50% necrosis. The maximum standardised uptake values (SUVmax) of the tumours on F-18 FDG-PET were measured. The mean values of SUVmax were compared between the two groups. The diagnostic performance of SUVmax in distinguishing the two groups was also evaluated using receiver operating characteristic analysis.

RESULTS

The mean SUVmax of the response group was higher than that of the non-response group (9.00 ± 1.78 versus 4.26 ± 2.35; p<0.001). The optimal cut-off value of SUVmax was 9.28 for distinguishing the two groups. The sensitivity, specificity, and accuracy for the prediction in the response group were 80%, 95.7%, and 92.9%, respectively.

CONCLUSIONS

SUVmax on F-18 FDG-PET may be useful as a biomarker to predict the pathological response to NAC in patients with PDAC.

Difference between carbohydrate antigen 19-9 and fluorine-18 fluorodeoxyglucose positron emission tomography in evaluating the treatment efficacy of neoadjuvant treatment in patients with resectable and borderline resectable pancreatic ductal adenocarcinoma: Results of a dual-center study

BACKGROUND

An accurate evaluation of neoadjuvant treatment is important to maximize the prognostic benefit of this strategy in each individual patient. The main aim of the present study is to investigate the difference between carbohydrate antigen 19-9 and fluorine-18 fluorodeoxyglucose positron emission tomography (FDG-PET) in evaluating the response to neoadjuvant treatment for resectable and borderline resectable pancreatic ductal adenocarcinoma (PDAC) patients.

METHODS

Pancreatic ductal adenocarcinoma patients with positive standard uptake values (SUV) on FDG-PET before neoadjuvant chemoradiotherapy (NACRT) were enrolled (n = 141). In all patients, CA19-9 and FDG-PET were evaluated before the initiation of and after the completion of NACRT. The statuses of CA19-9 and FDG uptake alterations during NACRT were assessed in association with survival and tumor recurrence profiles.

RESULTS

A favorable response in each CA19-9 and FDG-PET was significantly related to better survival, respectively, than the unfavorable response (44.3% vs 19.5%, P < .001 and 45.8% vs 24.6%, P < .001). The status of CA19-9 was significantly associated with the incidence of distant recurrence whereas the status of FDG-PET was significantly associated with the incidence of local recurrence, and only patients with a favorable response in both CA19-9 and PET statuses showed a significantly better survival than the others (5-year survival: 56% vs 24%, P < .001), and those with unfavorable response in either of CA19-9 or PET status showed similar poor survival to those with unfavorable in both (P = .164).

CONCLUSION

CA19-9 and PET evaluation provided oncologically different risk assessments in terms of tumor recurrence profile, and favorable response in both CA19-9 and FDG-PET were necessary to achieve prognostic benefit from NACRT.

Comparing prognostic factors of Glut-1 expression and maximum standardized uptake value by FDG-PET in patients with resectable pancreatic cancer

BACKGROUND

This study aimed to assess the prognostic values of preoperative maximum standardized uptake value (SUVmax) of primary pancreatic tumors and Glut-1 expression in patients with resectable pancreatic ductal adenocarcinoma (R-PDAC), and to investigate whether Glut-1 expression is more effective than SUVmax in predicting survival in patients with R-PDAC.

METHODS

We investigated 101 R-PDAC patients who underwent pancreatectomy for pancreatic cancer treatment. SUVmax analyzed through 18F-fluoro-2-deoxyglucose positron emission tomography/computed tomography (18F-FDG-PET/CT), and Glut-1 expression, were assessed for predicting the prognosis of patients with R-PDAC.

RESULTS

In patients with R-PDAC, the high SUVmax group (≥4.25) had significantly shorter overall survival (OS) and disease-free survival (DFS) than the low SUVmax group (＜4.25). Surprisingly, Glut-1 expression was not significantly correlated with SUVmax. Moreover, the high Glut-1 expression group, which was related to higher levels of CA 19-9, had significantly shorter OS and DFS than the low Glut-1 expression group. Furthermore, among the high SUVmax group, OS and DFS were significantly shorter in the high Glut-1 expression group. Multivariate analyses revealed that Glut-1 overexpression was an independent prognostic factor in patients with R-PDAC. Glut-1 knockdown also induced cell cycle arrest in PDAC cells in vitro.

CONCLUSIONS

The study determined that Glut-1 overexpression is a more powerful prognostic factor than SUVmax for predicting OS and higher risk of recurrence in R-PDAC patients. Glut-1 overexpression is also more likely to be associated with malignant activity in PDAC patients.

Prognosis prediction of pancreatic cancer after curative intent surgery using imaging parameters derived from F-18 fluorodeoxyglucose positron emission tomography/computed tomography

Imaging parameters including metabolic or textural parameters during F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) are being used for evaluation of malignancy. However, their utility for prognosis prediction has not been thoroughly investigated. Here, we evaluated the prognosis prediction ability of imaging parameters from preoperative FDGPET/CT in operable pancreatic cancer patients.Sixty pancreatic cancer patients (male:female = 36:24, age = 67.2 ± 10.5 years) who had undergone FDGPET/CT before the curative intent surgery were enrolled. Clinico-pathologic parameters, metabolic parameters from FDGPET/CT; maximal standard uptake value (SUVmax), glucose-incorporated SUVmax (GI-SUVmax), metabolic tumor volume, total-lesion glycolysis, and 53 textural parameters derived from imaging analysis software (MaZda version 4.6) were compared with overall survival.All the patients underwent curative resection. Mean and standard deviation of overall follow-up duration was 16.12 ± 9.81months. Among them, 39 patients had died at 13.46 ± 8.82 months after operation, whereas 21 patients survived with the follow-up duration of 18.56 ± 9.97 months. In the univariate analysis, Tumor diameter ≥4 cm (P = .003), Preoperative Carbohydrate antigen 19-9 ≥37 U/mL (P = .034), number of metastatic lymph node (P = .048) and GI-SUVmax (P = .004) were significant parameters for decreased overall survival. Among the textural parameters, kurtosis3D (P = .052), and skewness3D (P = .064) were potentially significant predictors in the univariate analysis. However, in multivariate analysis only GI-SUVmax (P = .026) and combined operation (P = .001) were significant independent predictors of overall survival.The current research result indicates that metabolic parameter (GI-SUVmax) from FDGPET/CT, and combined operation could predict the overall survival of surgically resected pancreatic cancer patients. Other metabolic or textural imaging parameters were not significant predictors for overall survival of localized pancreatic cancer.

Prognostic Implications of 18-FDG Positron Emission Tomography/Computed Tomography in Resectable Pancreatic Cancer

There are currently no known preoperative factors for determining the prognosis in pancreatic cancer. The aim of this study was to examine the role of 18-fluorodeoxyglucose (18-FDG) positron emission tomography/computed tomography (18-FDG-PET/CT) as a prognostic factor for patients with resectable pancreatic cancer. Data were obtained from a retrospective analysis of patients who had a preoperative PET scan and then underwent pancreatic resection from January 2007 to December 2015. The maximum standardized uptake value (SUVmax) of 18-FDG-PET/CT was calculated. Patients were divided into high (>3.65) and low (≤3.65) SUVmax groups, and compared in terms of their TNM classification (Union for International Cancer Contro classification), pathological grade, surgical treatment, state of resection margins, lymph node involvement, age, sex, diabetes and serum Carbohydrate Antigen 19-9 (CA 19-9) levels. The study involved 144 patients, 82 with high SUVmax pancreatic cancer and 62 with low SUVmax disease. The two groups' disease-free and overall survival rates were significantly influenced by tumor stage, lymph node involvement, pathological grade, resection margins and SUVmax. Patients with an SUVmax ≤ 3.65 had a significantly better survival than those with SUVmax > 3.65 (p < 0.001). The same variables were independent predictors of survival on multivariate analysis. The SUVmax calculated with 18-FDG-PET/CT is an important prognostic factor for patients with pancreatic cancer, and may be useful in decisions concerning patients' therapeutic management.

The efficacy of 18F-FDG PET/CT in the preoperative evaluation of pancreatic lesions

Purpose

Since the treatment strategy for benign and malignant pancreatic lesions differ, we aimed to evaluate the clinical value of PET/CT in the diagnosis and management of pancreatic lesions.

Methods

Ninety patients who had a histologically confirmed pancreatic lesion were studied. Receiver operating characteristic (ROC) curve analysis was used to investigate the ability of PET/CT to differentiate malignant lesions from benign tumors.

Results

The malignant and benign groups comprised 64 and 26 patients, respectively. Despite the similarity in the size of primary tumors (P = 0.588), the mean maximum standardized uptake values (SUVmax) obtained from PET/CT imaging were significantly higher in malignant lesions (9.36 ± 5.9) than those of benign tumors (1.04 ± 2.6, P < 0.001). ROC analysis showed that the optimal SUVmax cutoff value for differentiating malignant lesions (to an accuracy of 91%; 95% confidence interval, 83%-98%) from benign tumors was 3.9 (sensitivity, 92.2%; specificity, 84.6%).

Conclusion

PET/CT evaluation of pancreatic lesions confers advantages including fine assessment of malignant potential with high sensitivity and accuracy using a threshold SUVmax value of 3.9.

Early recurrence detected by 18F-FDG PET/CT in patients with resected pancreatic ductal adenocarcinoma

F-fluoro-2-deoxy-D-glucose positron emission tomography integrated with computed tomography (F-FDG PET/CT) has been proved to be practical in detecting occult malignant lesions. However, the evidence of its utility in detecting early recurrence after resection of pancreatic ductal adenocarcinoma (PDAC) is lacking. Therefore, the primary aim of the present study is to evaluate the diagnostic value of F-FDG PET/CT in the early postoperative period after radical resection of PDAC.This retrospective study included 32 patients who had F-FDG PET/CT scan within 6 months after radical resection of PDAC between January 2010 and December 2018.In total, 10 positive PET results were found at surgical margins of remnant pancreas, 12 at locoregional lymph nodes, 5 at distant areas, with the corresponding mean maximum standard uptake value (SUVmax) of 5.8 ± 1.1, 5.9 ± 0.9, and 6.4 ± 0.7, respectively. The median follow-up time was 23.5 months (range: 8-75 months), and the median survival time was 39.5 months (95% confidence interval: 14.6-64.4 months) for the entire cohort. Patients with positive PET findings at either locoregional lymph nodes or distant areas obtained significantly poorer overall survival (OS) than those without increased FDG uptake at the corresponding areas (P = .003 and P < .001, respectively). Whereas comparisons of OS between patients with or without increased FDG uptake at the surgical margin of remnant pancreas presented no statistically difference (P = .742).The early application of F-FDG PET/CT after radical resection of PDAC could stratify the prognosis of patients well by detecting occult early recurrence at locoregional lymph nodes and distant areas efficiently.

Role of imaging biomarkers for prognostic prediction in patients with pancreatic ductal adenocarcinoma

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive tumours. PDAC has a poor prognosis; therefore, it is necessary to perform further risk stratification. Identifying prognostic factors before treatment might help to implement suitable and personalised treatment for individuals and avoid side effects. Conventional staging systems and tumour biomarkers are fundamental to establish prognosis; however, they have obvious limitations. Novel imaging biomarkers extracted from advanced imaging techniques offer opportunities to evaluate underlying tumour physiological characteristics, such as mutational status, cellular composition, local microenvironment, tumour metabolism, and biological behaviour. Thus, imaging biomarkers might help the decision making of oncologists and surgeons. The present review discusses the functions of imaging biomarkers for prognostic prediction in patients with PDAC and their potential value for further translation in clinical practice.

[18F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer

Background

While [¹⁸F]fluoromisonidazole (FMISO), a representative PET tracer to detect hypoxia, is reported to be able to prospect the prognosis after treatment for various types of cancers, the relation is unclear for pancreatic cancer. The aim of this study is to assess the feasibility of [¹⁸F]FMISO PET/CT as a preoperative prognostic factor in patients with pancreatic cancer.

Methods

Patients with pancreatic cancer who had been initially planned for surgery received [¹⁸F]FMISO PET/CT. Peak standardized uptake value (SUV) of the pancreatic tumor was divided by SUVpeak of the aorta, and tumor blood ratio using SUVpeak (TBRpeak) was calculated. After preoperative examination, surgeons finally decided the operability of the patients. TBRpeak was compared with hypoxia-inducible factor (HIF)-1α immunohistochemistry when the tissues were available. Furthermore, correlation of TBRpeak with the recurrence-free survival and the overall survival were evaluated by Kaplan-Meyer methods.

Results

We analyzed 25 patients with pancreatic adenocarcinoma (11 women and 14 men, median age, 73 years; range, 58–81 years), and observed for 39–1101 days (median, 369 days). Nine cases (36.0%) were identified as visually positive of pancreatic cancer on [¹⁸F]FMISO PET/CT images. TBRpeak of the negative cases was significantly lower than that of the positive cases (median 1.08, interquartile range (IQR) 1.02–1.15 vs median 1.50, IQR 1.25–1.73, p < 0.001), and the cutoff TBRpeak was calculated as 1.24. Five patients were finally considered inoperable. There was no significant difference in TBRpeak of inoperable and operable patients (median 1.48, IQR 1.06–1.98 vs median 1.12, IQR 1.05–1.21, p = 0.10). There was no significant difference between TBRpeak and HIF-1α expression (p = 0.22). The patients were dichotomized by the TBRpeak cutoff, and the higher group showed significantly shorter recurrence-free survival than the other (median 218 vs 441 days, p = 0.002). As for overall survival of 20 cases of operated patients, the higher TBRpeak group showed significantly shorter overall survival than the other (median survival, 415 vs > 1000 days, p = 0.04).

Conclusions

[¹⁸F]FMISO PET/CT has the possibility to be a preoperative prognostic factor in patients with pancreatic cancer.

Electronic supplementary material

The online version of this article (10.1186/s13550-019-0507-8) contains supplementary material, which is available to authorized users.

Detecting tumour response and predicting resectability after neoadjuvant therapy for borderline resectable and locally advanced pancreatic cancer

BACKGROUND

This systematic review aimed to determine the accuracy of imaging modalities to predict resectability and R0 resection for borderline resectable (BRPC) or locally advanced pancreatic cancer (LAPC) after neoadjuvant therapy (NAT).

METHODS

A systematic search of major databases was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Fifteen studies identified 995 patients of which 683 had BRPC and 312 LAPC. Computed tomography (CT) scan was the most common modality for re-staging (n = 14), followed by positron emission tomography (PET)-CT (n = 3) and endosonography (EUS) (n = 2). Stable disease on RECIST criteria was found in 67% of patients (range 53-80%) with 20% demonstrating reduction in tumour size. A total of 60% of patients underwent surgery post-NAT (range 31-85%) with a R0 rate of 88% (range 57-100%). Accuracy for predicting R0 resectability and T-stage on CT scan was 71 and 49%. A reduction in SUVmax on PET-CT and reduction of tumour stiffness on EUS elastography positively correlated with resectability.

CONCLUSIONS

More than half the patients undergo resection post-NAT for LAPC and BRPC. Stable, or reduction of, tumour disease may predict resectability. Reduction in tumour SUVmax on PET-CT and decreased tumour stiffness on EUS elastography may be potential markers of NAT response and resectability.

Prognostic value of preoperative fluorodeoxyglucose positron emission tomography/computed tomography in patients with potentially resectable pancreatic cancer

PURPOSE

To evaluate the prognostic value of preoperative 18-fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in patients with potentially resectable pancreatic cancer.

METHODS

The study included 103 consecutive patients with potentially resectable pancreatic cancer who underwent preoperative FDG-PET/CT. Age, sex, blood glucose level, tumor marker levels (carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9)), PET-related parameters (maximum standardized uptake value (SUVmax)), and contrast-enhanced CT-related factors (tumor size, location, enhancement pattern, and CT-based T and N factors by tumor nodes metastasis (TNM) classification) were assessed for their ability to independently predict postoperative tumor recurrence using Cox proportional hazards model.

RESULTS

Median follow-up was 23.1 months. Univariate analyses revealed that SUVmax (P = 0.0004), tumor size (P = 0.0002), T factor (P = 0.0102), N factor (P = 0.0049), and CA19-9 levels (P = 0.0059) were significantly associated with disease-free survival (DFS). In multivariate analysis, SUVmax (P = 0.0163) and CA19-9 levels (P = 0.0364) independently predicted DFS. Kaplan-Meier analysis revealed that patients with low (< 2.5) SUVmax had a significantly better prognosis than those with higher SUVmax (P = 0.0006). The DFS in patients with SUVmax < 2.5 (n = 23) and SUVmax ≥ 2.5 (n = 80) was 61.9% and 9.7%, respectively, 3 years postoperatively.

CONCLUSIONS

SUVmax can predict DFS in patients with resectable pancreatic cancer. A SUVmax < 2.5 heralds a better prognosis.

Predictive Early Recurrence Factors of Preoperative Clinicophysiological Findings in Pancreatic Cancer

Background: We aimed to evaluate the use of preoperative clinicophysiological parameters as predictive risk factors for early recurrence of pancreatic ductal adenocarcinoma (PDAC) after curative resection. Methods: A total of 260 patients who underwent pancreatic resection for PDAC between 2007 and 2015 were examined retrospectively. We divided the patients into those with early recurrence (within 6 months; group A, n = 52) and those with relapse within ≥6 months or without recurrence (group B, n = 208). Data regarding clinicophysiological parameters were analyzed as predictors of disease-free survival (DFS). These factors were analyzed by χ2 tests on univariate analysis and Cox proportional hazard models on multivariate analyses. Kaplan-Meier survival curves were generated using log-rank tests. Results: Groups A and B had significantly different preoperative carbohydrate antigen 19-9 (CA19-9) levels, carcinoembryonic antigen (CEA) levels, and curability. Univariate and multivariate analysis showed that CA19-9 and CEA were independent prognostic factors for early recurrence. Patients with CA19-9 levels > 124.65 U/mL had significantly shorter DFS than those with lower levels, as did patients with CEA levels > 4.45 ng/mL. Conclusions: Our results show that elevated CA19-9 (> 124.65 U/mL) and CEA (> 4.45 ng/mL) were independent predictors of early recurrence after pancreatic resection in PDAC patients.

A nomogram for predicting survival of patients with locally advanced pancreatic cancer treated with chemoradiotherapy

BACKGROUND

We developed a nomogram for predicting survival of patients with locally advanced pancreatic cancer (LAPC) after concurrent chemoradiotherapy (CRT) using ¹⁸F-flurodeoxyglucose-positron emission tomography (FDG-PET) parameters and CA 19-9 levels.

METHODS

Based on 426 patients with LAPC who received concurrent CRT between 2004 and 2015, we investigated significant prognostic factors for survival to build a nomogram, including the maximum standardized uptake value (SUV_max) and CA 19-9 levels. Predictive accuracy and discriminative ability were then measured.

RESULTS

Median progression-free survival and overall survival (OS) were 9.4 and 15.4 months, respectively, at a median 15-month follow-up. High-dose radiation (EQD2, ≥61 Gy), initial SUV_max <3.5 and CA 19-9 ≤400 U/mL, and surgical resection after CRT were significantly related to prolonged OS by multivariate analysis (p < 0.05). A nomogram model for OS was established and showed good calibration and acceptable discrimination (c-index 0.656). Using the nomogram, 3 different prognosis groups could be identified with a median OS of 25, 15, and 11 months (p < 0.001).

CONCLUSION

A nomogram was developed with high-dose radiation (EQD2, ≥61 Gy), initial SUV_max <3.5, CA 19-9 ≤400 U/mL, and surgical resection after CRT for patients with LAPC. This will help in clinical decision-making and in selecting patients for CRT.

SUVmax after (18)fluoro-deoxyglucose positron emission tomography/computed tomography: A tool to define treatment strategies in pancreatic cancer

BACKGROUND

(18)fluoro-deoxyglucose positron emission tomography/computed tomography (18FDG-PET/CT) might be a useful tool in the management of pancreatic ductal adenocarcinoma (PDAC).

AIMS

The aim of this study was to analyze maximum standard uptake value (SUVmax) after 18FDG-PET/CT as predictor of survival outcomes and method to determine treatment strategies.

METHODS

A consecutive series of patients who underwent preoperative 18FDG-PET/CT and subsequent resection for PDAC were retrospectively reviewed. Patients who underwent neoadjuvant chemotherapy were excluded.

RESULTS

46 patients were included in the analysis. Median follow-up was 27 months (4-67). Patients who recurred within 12 months showed a significantly higher preoperative median SUVmax (8.1 vs 6.1, p=0.039). Receiver operating characteristics (ROC) curves for disease-free survival (DFS) and disease-specific survival (DSS) identified SUVmax of 6.0 as optimal cut-off. Multivariate analysis showed that SUVmax ≥ 6.0 was an independent predictor of poor DFS (HR 2.288, p=0.024) and DSS (HR 4.875, p<0.001). The combination of SUVmax ≥6.0 with CA19.9 ≥200U/ml was significantly associated with survival outcomes in comparison to patients without concordantly elevated values.

CONCLUSION

SUVmax ≥6.0 is an independent predictor of DFS and DSS in resected PDAC. 18FDG-PET/CT might be considered in the preoperative evaluation of patients with pancreatic cancer.

Prognostic value of 18F-FDG-PET/CT parameters in patients with pancreatic carcinoma: A systematic review and meta-analysis

BACKGROUND

The identification of pancreatic carcinoma (PC) patients with poor prognosis is a priority in clinical oncology because of their high 5-year mortality. However, the prognostic value of pretreatment F-fluorodeoxyglucose (F-FDG)- positron emission tomography (PET)/computed tomography (CT) parameters in PC patients is controversial and no consensus exists as to its predictive capability. This meta-analysis was performed to comprehensively explore the prognostic significance of F-FDG-PET/CT parameters in patients with pancreatic carcinoma.

METHODS

Extensive literature searches of the PubMed, Embase, Web of Science, and Cochrane Library databases were conducted to identify literature published until March 5, 2017. Comparative analyses of the pooled hazard ratios (HRs) for event-free survival (EFS) and overall survival (OS) were performed to assess their correlations with pretreatment maximum standardized uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG). Either the fixed- or the random-effects model was adopted, depending on the heterogeneity observed across studies. Subgroup and sensitivity analyses were performed to assess the robustness of the results.

RESULTS

Sixteen studies including 1146 patients were identified. The pooled HRs for the probability of EFS were 1.90 (95% confidential interval (CI): 1.48-2.45) for SUVmax, 1.76 (95% CI: 1.20-2.58) for MTV, and 1.81 (95% CI: 1.27-2.58) for TLG. The pooled HRs for the probability of OS were 1.21 (95% CI: 1.12-1.31) for SUVmax, 1.56 (95% CI: 1.13-2.16) for MTV, and 1.70 (95% CI: 1.25-2.30) for TLG. A slight publication bias was detected using Begg test. After adjustment using the trim and fill procedure, the corrected HRs were not significantly different. The results of the subgroup analyses by SUVmax, MTV, and TLG showed that these factors may have similar prognostic significance.

CONCLUSION

F-FDG-PET/CT parameters, such as SUVmax, MTV, and TLG, may be significant prognostic factors in patients with pancreatic carcinoma. F-FDG-PET/CT imaging could be a promising tool to provide prognostic information for these patients.

Beyond Correlations, Sensitivities, and Specificities: A Roadmap for Demonstrating Utility of Advanced Imaging in Oncology Treatment and Clinical Trial Design

Despite the widespread belief that advanced imaging should be very helpful in guiding oncology treatment decision and improving efficiency and success rates in treatment clinical trials, its acceptance has been slow. Part of this is likely attributable to gaps in study design and statistical methodology for these imaging studies. Also, results supporting the performance of the imaging in these roles have largely been insufficient to justify their use within the design of a clinical trial or in treatment decision making. Statistically significant correlations between the imaging results and clinical outcomes are often incorrectly taken as evidence of adequate performance. Assessments of whether the imaging can outperform standard techniques or meaningfully supplement them are also frequently neglected. This paper provides guidance on study designs and statistical analyses for evaluating the performance of advanced imaging in the various roles in treatment decision guidance and clinical trial conduct. Relevant methodology from the imaging literature is reviewed; gaps in the literature are addressed using related concepts from the more extensive genomic and in vitro biomarker literature.

FDG-PET predicts treatment efficacy and surgical outcome of pre-operative chemoradiation therapy for resectable and borderline resectable pancreatic cancer

BACKGROUND

The efficacy of neoadjuvant chemoradiotherapy (NACRT) for resectable and borderline resectable pancreatic cancer is important for predicting outcomes after radical surgery, but few clinical indicators predict outcome before resection. This study examined the utility of FDG-PET in predicting the efficacy of NACRT and outcome after radical surgery.

METHODS

Eighty-three pancreatic cancer patients who underwent FDG-PET before and after NACRT and had positive standard uptake values (SUVs) before NACRT were enrolled in this study. Peri-operative clinical factors, including FDG-PET findings, were examined to predict the efficacy of NACRT and outcome after surgery.

RESULTS

Evans grade I, IIA, IIB, III, and IV was determined in 11, 31, 27, 11, and 3 patients, respectively. The maximum SUVs after NACRT (post SUV-max) and tumor size were significantly decreased compared to pretreatment values (p < 0.001 and p = 0.007, respectively). The post SUV-max and regression index were significantly related to grade III/IV (p = 0.04 and p < 0.001, respectively), but only the regression index predicted NACRT efficacy (p = 0.002). The AUC of the regression index for the detection of grade III/IV was 0.822, and 13 of 14 grade III/IV patients were picked up using 50% as the threshold (p < 0.001). Patients with a regression index >50% had a significantly better prognosis after radical resection than patients with <50% (p = 0.032). Regression index as well as pathological lymph node status and resectability status were independent prognostic factors in multivariate analysis (exp 2.086, p = 0.043).

CONCLUSION

The regression index is potentially a good indicator of the efficacy of NACRT and outcome after radical resection for pancreatic cancer.

Quantitative Analysis of (18)F-Fluorodeoxyglucose Positron Emission Tomography Identifies Novel Prognostic Imaging Biomarkers in Locally Advanced Pancreatic Cancer Patients Treated With Stereotactic Body Radiation Therapy

PURPOSE

To identify prognostic biomarkers in pancreatic cancer using high-throughput quantitative image analysis.

METHODS AND MATERIALS

In this institutional review board-approved study, we retrospectively analyzed images and outcomes for 139 locally advanced pancreatic cancer patients treated with stereotactic body radiation therapy (SBRT). The overall population was split into a training cohort (n=90) and a validation cohort (n=49) according to the time of treatment. We extracted quantitative imaging characteristics from pre-SBRT (18)F-fluorodeoxyglucose positron emission tomography, including statistical, morphologic, and texture features. A Cox proportional hazard regression model was built to predict overall survival (OS) in the training cohort using 162 robust image features. To avoid over-fitting, we applied the elastic net to obtain a sparse set of image features, whose linear combination constitutes a prognostic imaging signature. Univariate and multivariate Cox regression analyses were used to evaluate the association with OS, and concordance index (CI) was used to evaluate the survival prediction accuracy.

RESULTS

The prognostic imaging signature included 7 features characterizing different tumor phenotypes, including shape, intensity, and texture. On the validation cohort, univariate analysis showed that this prognostic signature was significantly associated with OS (P=.002, hazard ratio 2.74), which improved upon conventional imaging predictors including tumor volume, maximum standardized uptake value, and total legion glycolysis (P=.018-.028, hazard ratio 1.51-1.57). On multivariate analysis, the proposed signature was the only significant prognostic index (P=.037, hazard ratio 3.72) when adjusted for conventional imaging and clinical factors (P=.123-.870, hazard ratio 0.53-1.30). In terms of CI, the proposed signature scored 0.66 and was significantly better than competing prognostic indices (CI 0.48-0.64, Wilcoxon rank sum test P<1e-6).

CONCLUSION

Quantitative analysis identified novel (18)F-fluorodeoxyglucose positron emission tomography image features that showed improved prognostic value over conventional imaging metrics. If validated in large, prospective cohorts, the new prognostic signature might be used to identify patients for individualized risk-adaptive therapy.

The clinical usefulness of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) in follow-up of curatively resected pancreatic cancer patients

BACKGROUND

Computed tomography and serum tumor markers have limited value in detecting recurrence after curative surgery of pancreatic cancer. This study evaluated the clinical utility of 18F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) in diagnosing recurrence.

METHODS

One hundred ten patients underwent curative resection of pancreatic cancer were enrolled. The diagnostic value of abdominal computed tomography (CT), PET-CT and serum carbohydrate antigen (CA) 19-9 concentration were compared. The prognostic value of SUVmax on PET-CT was evaluated.

RESULTS

PET-CT showed relatively higher sensitivity (84.5% vs. 75.0%) and accuracy (84.5% vs. 74.5%) than CT, whereas PET-CT plus CT showed greater sensitivity (97.6%) and accuracy (90.0%) than either alone. In detecting distant recurrences, PET-CT showed higher sensitivity (83.1% vs. 67.7%) than CT. Nineteen patients showed recurrences only on PET-CT, with eleven having invisible or suspected benign lesions on CT, and eight had recurrences in areas not covered by CT. SUVmax over 3.3 was predictive of poor survival after recurrence.

CONCLUSIONS

PET-CT in combination with CT improves the detection of recurrence. PET-CT was especially advantageous in detecting recurrences in areas not covered by CT. If active post-operative surveillance after curative resection of pancreatic cancer is deemed beneficial, then it should include PET-CT combined with CT.

Multimodality treatment of recurrent pancreatic cancer: Mith or reality?

Pancreatic adenocarcinoma is the fourth cause of cancer-related death in the United States. Surgery is the only potentially curative treatment, but most patients present at diagnosis with unresectable or metastatic disease. Moreover, even with an R0 resection, the majority of patients will die of disease recurrence. Most recurrences occur in the first 2-year after pancreatic resection, and are commonly located in the abdomen, even if distant metastases can occur. Recurrent pancreatic adenocarcinoma remains a significant therapeutic challenge, due to the limited role of surgery and radio-chemotherapy. Surgical management of recurrence is usually unreliable because tumor relapse typically presents as a technically unresectable, or as multifocal disease with an aggressive growth. Therefore, treatment of patients with recurrent pancreatic adenocarcinoma has historically been limited to palliative chemotherapy or supportive care. Only few data are available in the Literature about this issue, even if in recent years more studies have been published to determine whether treatment after recurrence have any effect on patients outcome. Recent therapeutic advances have demonstrated the potential to improve survival in selected patients who had undergone resection for pancreatic cancer. Multimodality management of recurrent pancreatic carcinoma may lead to better survival and quality of life in a small but significant percentage of patients; however, more and larger studies are needed to clarify the role of the different therapeutic options and the optimal way to combine them.

Hybrid imaging for pancreatic malignancy: clinical applications, merits, limitations, and pitfalls

The role of PET/CT in pancreatic malignancy is evolving with new scientific evidence emerging continuously. PET/CT applications in imaging the pancreas and its organ-specific merits, limitations, and potential pitfalls are still evolving. This article provides an overview of the state-of-the-art applications of PET/CT imaging in evaluating pancreatic malignancy, comparing with conventional imaging modalities, such as contrast-enhanced CT and MRI. Current PET/MRI is also reviewed, along with brief discussion on cost-benefit analysis.

Maximum standardized uptake value on 18F-fluoro-2-deoxy-glucose positron emission tomography/computed tomography and glucose transporter-1 expression correlates with survival in invasive ductal carcinoma of the pancreas

OBJECTIVES

The purpose of this study was to assess the correlations among the maximum standardized uptake value (SUVmax) on 18F-fluoro-2-deoxy-glucose positron emission tomography/computed tomography (FDG-PET/CT); the expressions of glucose transporter 1 (GLUT-1), glucose transporter 3, and epidermal growth factor receptor (EGFR); as well as prognosis in patients with invasive ductal carcinoma of the pancreas.

METHODS

A total of 41 patients with surgically resected and histologically proven invasive ductal carcinoma of the pancreas who underwent preoperative FDG-PET/CT were assessed. The SUVmax at the primary tumor site was measured by FDG-PET/CT, and immunohistochemical staining of tumor sections was performed for GLUT-1, glucose transporter 3, and EGFR.

RESULTS

Higher FDG uptake (SUVmax, >3.40) and GLUT-1 expression were significantly associated with shorter overall survival (P < 0.05). The SUVmax was not found to be significantly correlated with clinicopathological characteristics such as TNM classification, lymph node metastasis, and tumor differentiation. The EGFR expression was significantly correlated with the SUVmax (P = 0.024).

CONCLUSIONS

Higher FDG uptake and GLUT-1 expression in invasive ductal carcinoma of the pancreas seems to be an important prognostic factor. In addition, the EGFR expression was significantly correlated with the SUVmax.

Optimal duration of the early and late recurrence of pancreatic cancer after pancreatectomy based on the difference in the prognosis

BACKGROUND

The term "early recurrence" of pancreatic cancer has not been well-defined in most previous studies.

METHODS

The clinical records of 86 patients who underwent macroscopic curative pancreatectomy for pancreatic cancer between 2000 and 2009 were retrospectively examined. We divided 55 patients who experienced disease recurrence into two groups, the early and late recurrence groups, using the minimum p value approach. The relationships between the interval prior to recurrence and clinical outcomes were investigated.

RESULTS

The cumulative 5-year overall survival rates for all 86 patients were 30.2%. For 55 patients who experienced disease recurrence, the optimal cut-off value for differentiating early (n = 37) and late (n = 18) recurrence based on the overall survival was 12 months (p = 0.0000045). The Cox proportional hazard analysis identified carbohydrate antigen 19-9 > 100 U/ml (p = 0.017) and surgical margin (p = 0.007) as the independent prognostic factors associated with overall survival. Positive surgical margin (p = 0.037) and severe venous invasion (p = 0.005) were identified as independent factors associated with early recurrence.

CONCLUSION

Twelve months after pancreatectomy is the optimal cut-off value for defining early versus late recurrence based on the overall survival. Early recurrence was related to the status of the surgical margin and venous invasion.

Preoperative FDG-PET predicts early recurrence and a poor prognosis after resection of pancreatic adenocarcinoma

OBJECTIVE

The aim of this study was to evaluate the clinical utility of preoperative 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) as a prognostic predictor of resectable pancreatic adenocarcinoma.

METHODS

A total of 128 patients with resected pancreatic adenocarcinoma who preoperatively underwent FDG-PET examinations were studied. The maximum standard uptake value (SUVmax) was calculated for each primary lesion. A receiver operating characteristics (ROC) curve was constructed to estimate the optimal cutoff value of the SUVmax. In order to determine which outcomes of interest were appropriately demonstrated, ROC curve analyses were conducted for six outcomes: 6-, 12-, and 24-month disease-free survival (DFS), and 6-, 12-, and 24-month overall survival (OS). A multivariate analysis was conducted to identify prognostic factors.

RESULTS

The ROC curves revealed that the SUVmax predicted the 6-month DFS most optimally (area under the curve 0.757), with a cutoff value of 6.0. Of the 69 patients with an SUVmax ≥ 6.0, 34 (49 %) developed recurrence within 6 months. In contrast, only 3 of 59 (5 %) patients with an SUVmax < 6.0 exhibited early recurrence (p < 0.001). The median OS time was 37 months in patients with an SUVmax < 6.0 and 18 months in patients with an SUVmax ≥ 6.0 (p < 0.001). The multivariate analysis revealed lymph node metastasis (hazard ratio [HR] 2.31; p = 0.001) and an SUVmax ≥ 6.0 (HR 2.05; p = 0.002) to be significantly correlated with a poor survival.

CONCLUSIONS

An SUVmax ≥ 6.0 was a significant predictor of early postoperative recurrence and subsequent poor survival following resection of pancreatic adenocarcinoma.

Clinical usefulness of ¹⁸F-fluorodeoxyglucose-positron emission tomography in patients with locally advanced pancreatic cancer planned to undergo concurrent chemoradiation therapy

PURPOSE

To assess the role of coregistered (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in detecting radiographically occult distant metastasis (DM) at staging in patients with locally advanced pancreatic cancer (LAPC) and to study whether FDG-PET parameters can predict relatively long-term survival in patients who are more likely to benefit from chemoradiation therapy (CRT).

METHODS AND MATERIALS

From our institutional database, we identified 388 LAPC patients with M0 on conventional computed tomography (CT) who were planned to undergo CRT. Coregistered FDG-PET staging was offered to all patients, and follow-up FDG-PET was used at the clinical discretion of the physician.

RESULTS

FDG-PET detected unsuspected CT-occult DM in 33% of all 388 patients and allowed them to receive systemic therapy immediately. The remaining 260 patients (PET-M0) underwent CRT selectively as an initial treatment. Early DM arose in 13.1% of 260 patients, and the 1-year estimated locoregional recurrence rate was 5.4%. Median overall survival (OS) and progression-free survival (PFS) were 14.6 and 9.3 months, respectively, at a median follow-up time of 32.3 months (range, 10-99.1 months). Patients with a baseline standardized uptake value (SUV) <3.5 and/or SUV decline ≥60% had significantly better OS and PFS than those having none, even after adjustment for all potential confounding variables (all P<.001).

CONCLUSIONS

FDG-PET can detect radiographically occult DM at staging in one-third of patients and spare them from the potentially toxic therapy. Additionally, FDG-PET parameters including baseline SUV and SUV changes may serve as useful clinical markers for predicting the prognosis in LAPC patients.

Prognostic Value of Metabolic Tumor Volume and Total Lesion Glycolysis on Preoperative ¹⁸F-FDG PET/CT in Patients with Pancreatic Cancer

In this study, we aimed to assess the prognostic value of metabolic tumor volume (MTV) and total lesion glycolysis (TLG) measured on (18)F-FDG PET/CT in pancreatic cancer patients who underwent resection with curative intent.

METHODS

Eighty-seven patients with pancreatic ductal adenocarcinoma who underwent (18)F-FDG PET/CT and subsequent surgical resection with curative intent with (30 patients) or without (57 patients) neoadjuvant therapy were retrospectively enrolled. The maximum standardized uptake value (SUVmax), MTV, and TLG were measured on (18)F-FDG PET/CT in all patients. The prognostic significances of PET/CT parameters and tumor factors for recurrence-free survival (RFS) and overall survival (OS) were evaluated by univariate and multivariate analyses.

RESULTS

Of the 87 patients, 57 (64%) experienced recurrence during the follow-up period. The tumor size, pathologic T (pT) stage, SUVmax, MTV, and TLG were significant prognostic factors for both RFS and OS (P < 0.05) on univariate analyses, and the presence of lymph node metastasis showed significance only for predicting RFS (P < 0.05). On multivariate analyses, the tumor size, MTV, and TLG were independent prognostic factors for RFS, and pT stage, MTV, and TLG were independent prognostic factors for OS. For the 57 patients who did not undergo neoadjuvant treatment, MTV and TLG remained significant predictive factors for tumor recurrence, along with tumor size and SUVmax.

CONCLUSION

MTV and TLG are independent prognostic factors for predicting RFS and OS in patients with pancreatic cancer. Thus, (18)F-FDG PET/CT can provide useful prognostic information for patients undergoing resection of pancreatic cancer with curative intent irrespective of neoadjuvant treatment.

Pancreatic cancer: advances in treatment, results and limitations

BACKGROUND/AIMS

Pancreatic cancer remains a therapeutic challenge. Surgery is the only treatment with the chance of cure. The aim of this review is to summarize the present state-of-the-art surgical procedures in pancreatic cancer.

METHODS

The current literature was reviewed with regard to surgical approaches in pancreatic cancer. A focus was put on high-quality studies, reviews, systematic reviews and meta-analyses as well as recruiting studies highlighting innovative approaches.

RESULTS

Today, standard resections can be performed with mortality rates below 5% in specialized high-volume institutions. Extended approaches for locally advanced cancer are technically feasible, including venous resections, multivisceral resections and recurrence surgery. They can be carried out without increased morbidity and mortality, are not compromised by higher R1 or N+ rates, and can improve survival. Arterial tumor invasion is still regarded controversially and is oncologically questionable. All surgical approaches should be part of interdisciplinary multimodal treatment concepts to improve the patients' prognosis.

CONCLUSION

Surgery is the backbone of pancreatic cancer treatment in localized disease. Extended approaches are feasible in centers and show--except for arterial resections--good long-term outcome. Interdisciplinary therapy is an essential supplementation of all surgical approaches.

Role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in predicting the pathologic response to preoperative chemoradiation therapy in patients with resectable T3 pancreatic cancer

BACKGROUND

The purpose of this study was to evaluate whether (18)F-fluorodeoxyglucose positron emission tomography in combination with computed tomography (FDG-PET/CT) could correctly predict the pathologic response to preoperative chemoradiation therapy (CRT) for resectable pancreatic cancer.

METHODS

Each of the 40 patients underwent FDG-PET/CT before and after preoperative CRT. The maximum standard uptake value (SUV) was measured for the primary tumor before and after preoperative CRT, defined as pre-CRT SUV and post-CRT SUV, respectively. The proportional alteration of the SUV decline (regression index) between post-CRT SUV and pre-CRT SUV was also calculated. These three indicators were associated with the pathologic response.

RESULTS

Patients were classified as 21 responders and 19 nonresponders according to the histologic features. A pre-CRT SUV ≥ 4.7 was seen in 15 (71 %) of 21 responders and in 6 (32 %) of 19 nonresponders (p = 0.03). A regression index ≥ 0.46 was seen in 15 (71 %) responders and 5 (26 %) nonresponders (p = 0.01).

CONCLUSIONS

A better pathological response can be expected for pancreatic cancer patients who have a high regression index (≥ 0.46) and a high pre-CRT SUV (≥ 4.7). The SUV measurement using FDG-PET/CT is a useful tool for predicting the pathologic response to preoperative CRT.

State-of-the-art PET/CT of the pancreas: current role and emerging indications

Fused positron emission tomography (PET)/computed tomography (CT) is a recently developed technology that couples the functional information of PET with the anatomic details of CT. Integrated PET/CT scanners produce both PET and contrast material-enhanced CT images of the entire body in one setting. Typically, the amount of fluorine 18 (18F) fluorodeoxyglucose (FDG) uptake in normal pancreatic parenchyma is insignificant compared with that of the liver. However, both malignant (eg, adenocarcinoma) and benign (eg, acute pancreatitis) pancreatic conditions may demonstrate intense FDG uptake. PET/CT provides an opportunity to depict pancreatic tumors and distant metastases, perform preoperative staging, and monitor response to treatment, and it has proved useful in distinguishing postoperative fibrosis from recurrence. In selected cases, PET/CT findings may be used to help diagnose autoimmune pancreatitis mimicking a mass by depicting systemic involvement. PET/CT may also be used to direct biopsy to sites more likely to yield representative tumor tissue. Novel radiolabeled molecules, such as sigma-receptor ligands and 18F-3'-fluoro-3'-deoxy-l-thymidine (FLT), may play an even greater role in distinguishing tumor recurrence from postoperative fibrosis or inflammation.

Biliary obstruction induces extremely elevated serum CA 19-9 levels: case report

BACKGROUND

Assessment of carbohydrate antigen (CA) 19-9 levels is used for diagnosis and follow-up of pancreaticobiliary cancers, and high levels of this biomarker are suggestive of a malignancy. CA 19-9 may also be elevated in patients with conditions other than tumors, such as cholestasis, biliary obstruction, and cholecystitis.

CASE REPORT

A 50-year-old male patient presented with jaundice and elevated CA 19-9 levels (161,902 IU/ml). Repeated biopsies of the common bile duct revealed no malignancies. Radiological findings indicated a mass protruding through the common bile duct. Positron emission tomography demonstrated increased (18)F-fluoro2-deoxy-D-glucose uptake in the liver and a mass resembling metastasis was detected. A Whipple procedure was performed and demonstrated no tumor. Postoperatively, CA 19-9 levels decreased to within normal limits (27 IU/ml).

CONCLUSION

These results indicate that CA 19-9 levels should not be the sole criterion for a diagnosis of malignancy. Although other analytical tools may aid diagnosis, surgical exploration may be required in some instances to avoid misdiagnosis and determine whether radiological results are falsely positive.

Tumor aggressiveness and patient outcome in cancer of the pancreas assessed by dynamic 18F-FDG PET/CT

This study aimed to assess the role of a quantitative dynamic PET model in pancreatic cancer as a potential index of tumor aggressiveness and predictor of survival.

METHODS

Seventy-one patients with (18)F-FDG-avid adenocarcinoma of the pancreas before treatment were recruited, including 27 with localized tumors (11 underwent pancreatectomy, and 16 had localized nonresectable tumors) and 44 with metastatic disease. Dynamic (18)F-FDG PET images were acquired over a 60-min period, followed by a whole-body PET/CT study. Quantitative data measurements were based on a 2-compartment model, and the following variables were calculated: VB (fractional blood volume in target area), K(1) and k(2) (kinetic membrane transport parameters), k(3) and k(4) (intracellular (18)F-FDG phosphorylation and dephosphorylation parameters, respectively), and (18)F-FDG INF (global (18)F-FDG influx).

RESULTS

The single significant variable for overall survival (OS) in patients with localized disease was (18)F-FDG INF. Patients with a high (18)F-FDG INF (>0.033 min(-1)) had a median OS of 6 and 5 mo for nonresectable and resected tumors, respectively, versus 15 and 19 mo for a low (18)F-FDG INF in nonresectable and resected tumors, respectively (P < 0.04). In metastatic disease, multivariate analysis found VB, K(1), and k(3) to be significant variables for OS (P < 0.043, <0.031, and <0.009, respectively). Prognostic factors for OS in the entire group of patients that were significant at multivariate analysis were stage of disease, VB, K(1), and (18)F-FDG INF (P < 0.00035, <0.03, <0.024, and <0.008, respectively). Median OS for all patients with a high (18)F-FDG INF, low VB, and high K(1) was 3 mo, as opposed to 14 mo in patients with a low (18)F-FDG INF, high VB, and low K(1) (P < 0.021), irrespective of stage and resectability.

CONCLUSION

Quantitative (18)F-FDG kinetic parameters measured by dynamic PET in newly diagnosed pancreatic cancer correlated with the aggressiveness of disease. The (18)F-FDG INF was the single most significant variable for OS in patients with localized disease, whether resectable or not.

Current state of surgical management of pancreatic cancer

Pancreatic cancer is still associated with a poor prognosis and remains—as the fourth leading cause of cancer related mortality—a therapeutic challenge. Overall long-term survival is about 1–5%, and in only 10–20% of pancreatic cancer patients is potentially curative surgery possible, increasing five-year survival rates to approximately 20–25%. Pancreatic surgery is a technically challenging procedure and has significantly changed during the past decades with regard to technical aspects as well as perioperative care. Standardized resections can be carried out with low morbidity and mortality below 5% in high volume institutions. Furthermore, there is growing evidence that also more extended resections including multivisceral approaches, vessel reconstructions or surgery for tumor recurrence can be carried out safely with favorable outcomes. The impact of adjuvant treatment, especially chemotherapy, has increased dramatically within recent years, leading to significantly improved postoperative survival, making pancreatic cancer therapy an interdisciplinary approach to achieve best results.