Positron emission tomography modalities prevent futile radical resection of pancreatic cancer: A meta-analysis

Novel Somay's GLUCAR Index Efficiently Predicts Survival Outcomes in Locally Advanced Pancreas Cancer Patients Receiving Definitive Chemoradiotherapy: A Propensity-Score-Matched Cohort Analysis

BACKGROUND

Propensity score matching (PSM) was used to investigate the prognostic value of a novel GLUCAR index [Glucose × (C-reactive protein ÷ albumin)] in unresectable locally advanced pancreatic cancer (LA-NPC) patients who received definitive concurrent chemoradiotherapy (CCRT).

METHODS

The PSM analysis comprised 142 LA-PAC patients subjected to definitive CCRT. Receiver operating characteristic (ROC) curve analysis was utilized to identify relevant pre-CCRT cutoffs that could effectively stratify survival results. The primary and secondary objectives were the correlations between the pre-CCRT GLUCAR measures and overall survival (OS) and progression-free survival (PFS).

RESULTS

The ROC analysis revealed significance at 43.3 for PFS [area under the curve (AUC): 85.1%; sensitivity: 76.8%; specificity: 74.2%; J-index: 0.510)] and 42.8 for OS (AUC: 81.8%; sensitivity: 74.2%; specificity: 71.7%; J-index: 0.459). Given that these cutoff points were close, the standard cutoff point, 42.8, was selected for further analysis. Comparative survival analyses showed that pre-CCRT GLUCAR ≥ 42.8 (n = 71) measures were associated with significantly shorter median PFS (4.7 vs. 15.8 months; p < 0.001) and OS (10.1 vs. 25.4 months; p < 0.001) durations compared to GLUCAR < 42.8 measures (n = 71). The multivariate analysis results confirmed the independent significance of the GLUCAR index on PFS (p < 0.001) and OS (p < 0.001) outcomes.

CONCLUSIONS

Elevated pre-CCRT GLUCAR levels are robustly and independently linked to significantly poorer PFS and OS outcomes in unresectable LA-PAC patients treated with definitive CCRT.

Quarter-Century PET/Computed Tomography Transformation of Oncology: Hepatobiliary and Pancreatic Cancer

[18F] Fluorodeoxyglucose (18F-FDG) PET/CT can improve the staging accuracy and clinical management of patients with hepatobiliary and pancreatic cancers, by detection of unsuspected metastases. 18F-FDG PET/CT metabolic parameters are valuable in predicting treatment response and survival. Metabolic response on 18F-FDG PET/CT can predict preoperative pathologic response to neoadjuvant therapy in patients with pancreatic cancer and determine prognosis. Several novel non-FDG tracers, such as 68Ga prostate-specific membrane antigen (PSMA) and 68Ga-fibroblast activation protein inhibitor (FAPI) PET/CT, show promise for imaging hepatobiliary and pancreatic cancers with potential for radioligand therapy.

Pancreatic ductal adenocarcinoma (PDAC) regional nodal disease at standard lymphadenectomy: is MRI accurate for identifying node-positive patients?

OBJECTIVE

To determine the accuracy of qualitative and quantitative MRI features for the diagnosis of pathologic regional lymph nodes at standard lymphadenectomy in patients with pancreatic ductal adenocarcinoma (PDAC).

METHODS

All adult patients with pancreatic MRI performed from 2011 to 2021 within 3 months of a pancreaticoduodenectomy were eligible for inclusion in this single-center retrospective cohort study. Regional nodes at standard lymphadenectomy were independently reviewed by two fellowship-trained abdominal radiologists for the following qualitative features: heterogeneous T2 signal, round shape, indistinct margin, peri-nodal fat stranding, and restricted diffusion greater than the spleen. Quantitative characteristics including primary tumor size, largest node short- and long-axes length, number of regional nodes, absolute apparent diffusion coefficient (ADC) values, and ADC node-to-spleen signal index were assessed. Analysis was at the patient-level with surgical pathology as the reference standard.

RESULTS

Of 75 patients, 85% (64/75) were positive for regional nodal disease on histopathology. None of the qualitative variables evaluated on MRI was associated with pathologic nodes. Median primary tumor maximum diameter was slightly larger for patients with pathologic nodes compared to those without (18 mm (10-42 mm) vs 16 mm (9-22 mm), p = 0.027). None of the other quantitative features was associated with pathologic nodes. Radiologist opinion was not associated with pathologic nodes (p = 0.520). Interobserver agreement was fair (kappa = 0.257).

CONCLUSIONS

Lymph node morphologic features and radiologist opinion using MRI are of limited value for diagnosing PDAC regional nodal disease. Improved diagnostic techniques are needed given the prognostic implications of pathologic lymph nodes in these patients.

KEY POINTS

• Multiple lymph node morphologic features routinely assessed on MRI for malignancies elsewhere in the body are likely not applicable when assessing for pancreatic ductal adenocarcinoma nodal disease. • Interobserver agreement for the presence or absence of pancreatic ductal adenocarcinoma lymph node morphologic features on MRI is fair (kappa = 0.257). • Many more lymph nodes are resected at PDAC standard lymphadenectomy than are detectable on MRI, median 25 vs 5 (p < 0.001), suggesting improved diagnostic techniques are needed to identify PDAC nodal disease.

Pancreatic cancer in 2021: What you need to know to win

Pancreatic cancer is one of the solid tumors with the worst prognosis. Five-year survival rate is less than 10%. Surgical resection is the only potentially curative treatment, but the tumor is often diagnosed at an advanced stage of the disease and surgery could be performed in a very limited number of patients. Moreover, surgery is still associated with high post-operative morbidity, while other therapies still offer very disappointing results. This article reviews every aspect of pancreatic cancer, focusing on the elements that can improve prognosis. It was written with the aim of describing everything you need to know in 2021 in order to face this difficult challenge.

The clinical application of 18F-FDG PET/CT in pancreatic cancer: a narrative review

Pancreatic cancer is one of the worst prognoses of all malignant tumors, with an annual incidence near its annual mortality rate. To improve the prognosis of patients with pancreatic cancer, it is essential to diagnose and evaluate pancreatic cancer early. Imaging examinations play an essential role in tumor detection, staging, and surgical resection assessment and can provide reliable evidence for the diagnosis and treatment of pancreatic cancer. Currently, imaging techniques commonly used for pancreatic cancer include endoscopic ultrasound (EUS), conventional ultrasound, magnetic resonance imaging (MRI), multidetector spiral computed tomography (MDCT), positron emission tomography/computed tomography (PET/CT), and others PET/CT is a new imaging device composed of PET and CT. ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG) is a commonly used tracer in the clinic. Cancer cells are more robust than other ordinary cells in that they can ingest glucose, and the structure of glucose is similar to the structure of ¹⁸F-FDG. Therefore, after the injection of ¹⁸F-FDG, ¹⁸F-FDG in tumor cells appears very thick during PET scanning. Therefore, PET/CT can determine the metabolic capacity and anatomical position of pancreatic tumor cells in the body accurately diagnose the patient's condition and tumor location. It plays a vital role in early diagnosis and accurate staging, predicts survival, and monitors therapeutic effectiveness and pancreatic cancer recurrence. Although ¹⁸F-FDG PET/CT has limitations in identifying inflammatory diseases and tumors, it still has good development potential. This article reviews the clinical application of ¹⁸F-FDG PET/CT in pancreatic cancer.

Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer

Simple Summary

Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life.

Abstract

Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.

Overlooked risk for needle tract seeding following endoscopic ultrasound-guided minimally invasive tissue acquisition

Endoscopic ultrasound-guided minimally invasive tissue acquisition can be performed by two approaches as follows: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) and endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB). These have been evolved into leading approaches and widely used for the histological diagnosis of tumors in the gastrointestinal tract and adjacent organs. However, the role of EUS-FNA and EUS-FNB in disease diagnosis and evaluation remains controversial. Although the incidence of surgery-associated complications remains low, the consequences of needle tract seeding can be serious or even life-threatening. Recently, increasing case reports of needle tract seeding are emerging, especially caused by EUS-FNA. This complication needs serious consideration. In the present work, we integrated these case reports and the related literature, and summarized the relevant cases and technical characteristics of needle tract seeding caused by EUS-FNA and EUS-FNB. Collectively, our findings provided valuable insights into the prevention and reduction of such serious complication.

The Role of Positron Emission Tomography in Pancreatic Cancer and Gallbladder Cancer

18F-FDG-PET is complementary to conventional imaging in patients with clinical suspicion for exocrine pancreatic malignancies. It has similar if not superior sensitivity and specificity for detection of cancer, and when combined with contrast enhanced anatomic imaging of the abdomen, can improve diagnostic accuracy and aid in staging, assessment for resectability, radiation therapy planning, and prognostication. Various metabolic pathways affect FDG uptake in pancreatic ductal adenocarcinoma. The degree of uptake reflects histopathology, aggressiveness, metastatic potential, and metabolic profile of malignant cell and their interaction with cancer stroma. After treatment, FDG-PET is useful for detection of residual or recurrent cancer and can be used to assess and monitor response to therapy in unresectable or metastatic disease. The degree and pattern of uptake combined with other imaging features are useful in characterization of incidental pancreatic lesions and benign processes such as inflammation. Several novel PET radiopharmaceuticals have been developed to improve detection and management of pancreatic cancer. Gallbladder carcinoma is typically FDG avid and when anatomic imaging is equivocal PET can be used to assess metastatic involvement with high specificity and inform subsequent management.

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.

The Utility of PET/Computed Tomography for Radiation Oncology Planning, Surveillance, and Prognosis Prediction of Gastrointestinal Tumors

At present, the strongest evidence for the use of PET/computed tomography (CT) in gastrointestinal (GI) malignancies is to rule out distant metastatic disease at diagnosis, radiation treatment planning for anal malignancies, and disease recurrence monitoring in colorectal and anal malignancies. Use of PET/CT for GI malignancies continues to evolve over time, with new studies evaluating prognostic abilities of PET/CT and with increasing sensitivity and spatial resolution of more modern PET/CT scanners. The authors encourage future applications and prospective evaluation of the use of PET/CT in the staging, prognostication, and recurrence prediction for GI malignancies.

Clinical and prognostic value of 18F-FDG-PET/CT in restaging of pancreatic cancer

AIM

The aim of this retrospective multicentre study was to evaluate the clinical and prognostic effect of fluorine-18-fluorodeoxyglucose (F-FDG)-PET/computed tomography (CT) in the restaging process of pancreatic cancer (PC).

MATERIALS AND METHODS

Data from patients treated for primary PC, who underwent F-FDG-PET/CT for suspicious of disease progression, were collected. Accuracy was assessed employing conventional diagnostic procedures, multidisciplinary team case notes, further F-FDG-PET/CT scans and/or follow-up. Receiver operating characteristic curve and likelihood ratio (LR+/-) analyses were used for completion of accuracy definition. Progression-free survival (PFS) and overall survival were assessed by using Kaplan-Meier method. The Cox proportional hazards model was used to identify predictors of outcome.

RESULTS

Fifty-two patients (33 males and 19 females, with mean age of 59 years and range: 42-78 years) with PC were finally included in our study. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of F-FDG-PET were 85, 84, 90, 76, and 84%, respectively. Area under the curve was 0.84 (95% confidence intervals: 0.72-0.96; P<0.05). LR+ and LR- were 5.3 and 0.17, respectively. F-FDG-PET/CT revealed new metastatic foci in 5/52 patients (10%) and excluded suspicious lesions in 11/52 (21%). Analysis of PFS revealed F-FDG-PET/CT positivity to be associated with a worse cumulative survival rate over a 6 and 12-month period in comparison with F-FDG-PET/CT negativity (6-month PFS 95 vs. 67%, P<0.05; 12-month PFS 81 vs. 29%, P<0.05). A negative F-FDG-PET/CT result was associated with a significantly longer overall survival than a positive one (70 vs. 26% after 2 years, P<0.05). In addition, a positive F-FDG-PET/CT scan result and an maximum standardized uptake value (SUVmax) value more than 6 were significantly associated with an increased risk of disease progression (PET positivity hazard ratio=3.9, P=0.01; SUVmax>6 h=4.2, P=0.02) and death (PET positivity hazard ratio=3.5, P=0.02; SUVmax>6 h=3.7, P=0.01).

CONCLUSION

F-FDG-PET/CT showed high diagnostic accuracy for restaging process of PC, proving also its potential value in predicting clinical outcome after primary treatment.