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Pancreatic Cancer

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Nuclear Oncology

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Abstract

Epithelial tumors of the pancreas are the third most common malignancy of the gastrointestinal tract (incidence of 11.7 per 100,000). Since most pancreatic cancer cases are diagnosed after the cancer has already metastasized (distant stage), the overall 5-year relative survival rate is 5.5%. Early detection of pancreatic cancer is the only way to improve its prognosis. Physical examination rarely confirms the diagnosis of localized pancreatic cancer. Carbohydrate antigen 19-9 (CA 19.9) is the most commonly employed serum marker in pancreatic cancer. However, the specificity for detecting pancreatic cancer is low (67.5%).

Computed tomography, magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography are the most widely applied methods for diagnosis and staging of pancreatic cancer. [18F]FDG-PET/CT may be helpful in the initial approach to a patient suspected of bearing pancreatic carcinoma (sensitivity 85–100% and specificity 67–90%) by aiding to differentiate benign from malignant lesions without the need for biopsy or surgery. However, false-positive findings at [18F]FDG-PET can be related to chronic pancreatitis; therefore, preliminary assay of the C-reactive protein serum level is recommended. Moreover, since mucinous pancreatic cancers usually do not have a high glucidic metabolism, they could be cause of false-negative reports. A further application of [18F]FDG-PET/CT at initial diagnosis can be as a guide for biopsy sampling. The staging for pancreatic exocrine cancer, according to the American Joint Committee on Cancer (AJCC), is necessary to obtain a uniform definition of disease. Surgical resection (stages I and II) remains the primary modality leading to the higher long-term survival (18–24%), whereas the role of postoperative chemotherapy or chemoradiotherapy remains debated. Regarding T staging, at present there are no data to support the usefulness of hybrid-modality PET/CT in local T staging. Moreover, as conventional imaging, [18F]FDG-PET/CT has low sensitivity (30–40%) for detecting LN metastasis. Conversely, [18F]FDG-PET has a higher diagnostic accuracy in the detection of distant metastasis (liver and peritoneum) compared with other modalities. Regarding the assessment of therapy response, the identification of early responders to chemotherapy is important in order to avoid unnecessary toxicity in patients who are not going to respond. [18F]FDG-PET may provide a sensitive parameter for earlier assessment of response to therapy versus conventional imaging. Moreover, besides serum CA 19.9, it is a reference tool for the evaluation of tumor response to neoadjuvant chemotherapy. In patients with raising serum CA 19.9 and conventional imaging is negative for recurrence, [18F]FDG-PET can detect unexpected sites of recurrence On the other hand, [18F]FDG-PET can also exclude the presence of recurrence when other imaging modalities are indeterminate or equivocal. [18F]FDG-PET seems to be a useful tool for prognosis since a negative PET scan at 1 month postchemotherapy is correlated with longer overall survival. Current literature shows that the accuracy of target volume delineation can be improved beyond the mere CT-based delineation by integrating PET and CT information. Radiopharmaceuticals whose uptake is related to proliferative activity (such as radiolabeled thymidine analog fluorothymidine) are, in principle, more suitable for discriminating cancers from inflammation than [18F]FDG. However, no enough data have been reported in humans.

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Authors and Affiliations

  1. Department of Nuclear Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Via Massarenti 9, Bologna, 40138, Italy

    Stefano Fanti MD & Anna Margherita Maffione MD

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  1. Stefano Fanti MD
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  2. Anna Margherita Maffione MD
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Correspondence to Stefano Fanti MD .

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Editors and Affiliations

  1. Dept. Radiology, Div. Nuclear Medicine, Memorial Sloan-Kettering Cancer Center, York Ave. 1275, New York, 10021, New York, USA

    H. William Strauss

  2. Centro Regionale di Medicina Nucleare, Universita di Pisa, Via Roma 67, Pisa, 56100, Italy

    Giuliano Mariani

  3. Centro Regionale di Medicina Nucleare, Universita di Pisa, Via Roma 67, Pisa, 56100, Italy

    Duccio Volterrani

  4. Cancer Center, Department of Radiology, Memorial Sloan-Kettering, York Ave. 1275, New York, 10021, New York, USA

    Steven M. Larson

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Fanti, S., Maffione, A.M. (2013). Pancreatic Cancer. In: Strauss, H., Mariani, G., Volterrani, D., Larson, S. (eds) Nuclear Oncology. Springer, New York, NY. https://doi.org/10.1007/978-0-387-48894-3_17

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