World Journal of Surgery

, Volume 37, Issue 1, pp 169–178 | Cite as

Role of 18F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography in Predicting the Pathologic Response to Preoperative Chemoradiation Therapy in Patients With Resectable T3 Pancreatic Cancer

  • Hirotada Kittaka
  • Hidenori Takahashi
  • Hiroaki Ohigashi
  • Kunihito Gotoh
  • Terumasa Yamada
  • Yasuhiko Tomita
  • Yoshihisa Hasegawa
  • Masahiko Yano
  • Osamu Ishikawa



The purpose of this study was to evaluate whether 18F-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.


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.


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).


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.


Pancreatic Cancer Standard Uptake Value Pathologic Response Regression Index Nonresponder Group 



This study was supported in part by a Grant from the Mitsui Life Welfare Foundation and a grant from the Otsuka Research Fund.

Conflict of interest

There are no commercial interests in the subject of this study.


  1. 1.
    Cameron JL, Crist DW, Sitzmann JV et al (1991) Factors influencing survival after pancreaticoduodenectomy for pancreatic cancer. Am J Surg 161:120–124 discussion 124–125PubMedCrossRefGoogle Scholar
  2. 2.
    Conlon KC, Klimstra DS, Brennan MF (1996) Long-term survival after curative resection for pancreatic ductal adenocarcinoma: clinicopathologic analysis of 5-year survivors. Ann Surg 223:273–279PubMedCrossRefGoogle Scholar
  3. 3.
    Willett CG, Lewandrowski K, Warshaw AL et al (1993) Resection margins in carcinoma of the head of the pancreas: implications for radiation therapy. Ann Surg 217:144–148PubMedCrossRefGoogle Scholar
  4. 4.
    Staley CA, Lee JE, Cleary KR et al (1996) Preoperative chemoradiation, pancreaticoduodenectomy, and intraoperative radiation therapy for adenocarcinoma of the pancreatic head. Am J Surg 171:118–124 discussion 124–115PubMedCrossRefGoogle Scholar
  5. 5.
    Breslin TM, Hess KR, Harbison DB et al (2001) Neoadjuvant chemoradiotherapy for adenocarcinoma of the pancreas: treatment variables and survival duration. Ann Surg Oncol 8:123–132PubMedCrossRefGoogle Scholar
  6. 6.
    Kamthan AG, Morris JC, Dalton J et al (1997) Combined modality therapy for stage II and stage III pancreatic carcinoma. J Clin Oncol 15:2920–2927PubMedGoogle Scholar
  7. 7.
    Mehta VK, Fisher G, Ford JA et al (2001) Preoperative chemoradiation for marginally resectable adenocarcinoma of the pancreas. J Gastrointest Surg 5:27–35PubMedCrossRefGoogle Scholar
  8. 8.
    Pendurthi TK, Hoffman JP, Ross E et al (1998) Preoperative versus postoperative chemoradiation for patients with resected pancreatic adenocarcinoma. Am Surg 64:686–692PubMedGoogle Scholar
  9. 9.
    Snady H, Bruckner H, Cooperman A et al (2000) Survival advantage of combined chemoradiotherapy compared with resection as the initial treatment of patients with regional pancreatic carcinoma: an outcomes trial. Cancer 89:314–327PubMedCrossRefGoogle Scholar
  10. 10.
    Talamonti MS, Small W Jr, Mulcahy MF et al (2006) A multi-institutional phase II trial of preoperative full-dose gemcitabine and concurrent radiation for patients with potentially resectable pancreatic carcinoma. Ann Surg Oncol 13:150–158PubMedCrossRefGoogle Scholar
  11. 11.
    Chun YS, Cooper HS, Cohen SJ et al (2011) Significance of pathologic response to preoperative therapy in pancreatic cancer. Ann Surg Oncol 18:3601–3607PubMedCrossRefGoogle Scholar
  12. 12.
    White RR, Xie HB, Gottfried MR et al (2005) Significance of histological response to preoperative chemoradiotherapy for pancreatic cancer. Ann Surg Oncol 12:214–221PubMedCrossRefGoogle Scholar
  13. 13.
    Delbeke D, Martin WH (2001) Positron emission tomography imaging in oncology. Radiol Clin North Am 39:883–917PubMedCrossRefGoogle Scholar
  14. 14.
    Hustinx R, Benard F, Alavi A (2002) Whole-body FDG-PET imaging in the management of patients with cancer. Semin Nucl Med 32:35–46PubMedCrossRefGoogle Scholar
  15. 15.
    Kubota K (2001) From tumor biology to clinical PET: a review of positron emission tomography (PET) in oncology. Ann Nucl Med 15:471–486PubMedCrossRefGoogle Scholar
  16. 16.
    Okamoto K, Koyama I, Miyazawa M et al (2011) Preoperative [18F]-fluorodeoxyglucose positron emission tomography/computed tomography predicts early recurrence after pancreatic cancer resection. Int J Clin Oncol 16:39–44PubMedCrossRefGoogle Scholar
  17. 17.
    Hopkins S, Fakih M, Yang GY (2010) Positron emission tomography as predictor of rectal cancer response during or following neoadjuvant chemoradiation. World J Gastrointest Oncol 2:213–217PubMedCrossRefGoogle Scholar
  18. 18.
    Kwee RM (2010) Prediction of tumor response to neoadjuvant therapy in patients with esophageal cancer with use of 18F FDG PET: a systematic review. Radiology 254:707–717PubMedCrossRefGoogle Scholar
  19. 19.
    Choi M, Heilbrun LK, Venkatramanamoorthy R et al (2010) Using 18F-fluorodeoxyglucose positron emission tomography to monitor clinical outcomes in patients treated with neoadjuvant chemo-radiotherapy for locally advanced pancreatic cancer. Am J Clin Oncol 33:257–261PubMedGoogle Scholar
  20. 20.
    Sobin L, Gospodarowicz M, Wittekind C (eds) (2010) TNM Classification of Malignant Tumors, 7th edn. Wiley-Blackwell, New YorkGoogle Scholar
  21. 21.
    Ohigashi H, Ishikawa O, Eguchi H et al (2009) Feasibility and efficacy of combination therapy with preoperative full-dose gemcitabine, concurrent three-dimensional conformal radiation, surgery, and postoperative liver perfusion chemotherapy for T3-pancreatic cancer. Ann Surg 250:88–95PubMedCrossRefGoogle Scholar
  22. 22.
    Evans DB, Rich TA, Byrd DR et al (1992) Preoperative chemoradiation and pancreaticoduodenectomy for adenocarcinoma of the pancreas. Arch Surg 127:1335–1339PubMedCrossRefGoogle Scholar
  23. 23.
    Eisenhauer EA, Therasse P, Bogaerts J et al (2009) New response evaluation criteria in solid tumours: revised RECIST guideline (version 1.1). Eur J Cancer 45:228–247PubMedCrossRefGoogle Scholar
  24. 24.
    Brucher BL, Weber W, Bauer M et al (2001) Neoadjuvant therapy of esophageal squamous cell carcinoma: response evaluation by positron emission tomography. Ann Surg 233:300–309PubMedCrossRefGoogle Scholar
  25. 25.
    Flamen P, Van Cutsem E, Lerut A et al (2002) Positron emission tomography for assessment of the response to induction radiochemotherapy in locally advanced oesophageal cancer. Ann Oncol 13:361–368PubMedCrossRefGoogle Scholar
  26. 26.
    Wieder HA, Brucher BL, Zimmermann F et al (2004) Time course of tumor metabolic activity during chemoradiotherapy of esophageal squamous cell carcinoma and response to treatment. J Clin Oncol 22:900–908PubMedCrossRefGoogle Scholar
  27. 27.
    Van Heijl M, Omloo JM, van Berge Henegouwen MI et al (2011) Fluorodeoxyglucose positron emission tomography for evaluating early response during neoadjuvant chemoradiotherapy in patients with potentially curable esophageal cancer. Ann Surg 253:56–63PubMedCrossRefGoogle Scholar
  28. 28.
    Cascini GL, Avallone A, Delrio P et al (2006) 18F-FDG PET is an early predictor of pathologic tumor response to preoperative radiochemotherapy in locally advanced rectal cancer. J Nucl Med 47:1241–1248PubMedGoogle Scholar
  29. 29.
    Capirci C, Rampin L, Erba PA et al (2007) Sequential FDG-PET/CT reliably predicts response of locally advanced rectal cancer to neo-adjuvant chemo-radiation therapy. Eur J Nucl Med Mol Imaging 34:1583–1593PubMedCrossRefGoogle Scholar
  30. 30.
    Hur H, Kim NK, Yun M et al (2011) 18Fluoro-deoxy-glucose positron emission tomography in assessing tumor response to preoperative chemoradiation therapy for locally advanced rectal cancer. J Surg Oncol 103:17–24PubMedCrossRefGoogle Scholar
  31. 31.
    Hawkins DS, Schuetze SM, Butrynski JE et al (2005) [18F]Fluorodeoxyglucose positron emission tomography predicts outcome for Ewing sarcoma family of tumors. J Clin Oncol 23:8828–8834PubMedCrossRefGoogle Scholar
  32. 32.
    Evilevitch V, Weber WA, Tap WD et al (2008) Reduction of glucose metabolic activity is more accurate than change in size at predicting histopathologic response to neoadjuvant therapy in high-grade soft-tissue sarcomas. Clin Cancer Res 14:715–720PubMedCrossRefGoogle Scholar
  33. 33.
    Benz MR, Czernin J, Tap WD, et al (2010) FDG-PET/CT imaging predicts histopathologic treatment responses after neoadjuvant therapy in adult primary bone sarcomas. Sarcoma 143540. Epub Apr 18Google Scholar
  34. 34.
    Cerfolio RJ, Bryant AS, Winokur TS et al (2004) Repeat FDG-PET after neoadjuvant therapy is a predictor of pathologic response in patients with non-small cell lung cancer. Ann Thorac Surg 78:1903–1909 discussion 1909PubMedCrossRefGoogle Scholar
  35. 35.
    Shiraishi K, Nomori H, Ohba Y et al (2010) Repeat FDG-PET for predicting pathological tumor response and prognosis after neoadjuvant treatment in nonsmall cell lung cancer: comparison with computed tomography. Ann Thorac Cardiovasc Surg 16:394–400PubMedGoogle Scholar
  36. 36.
    Schellenberg D, Quon A, Minn AY et al (2010) 18Fluorodeoxyglucose PET is prognostic of progression-free and overall survival in locally advanced pancreas cancer treated with stereotactic radiotherapy. Int J Radiat Oncol Biol Phys 77:1420–1425PubMedCrossRefGoogle Scholar
  37. 37.
    Nakata B, Chung YS, Nishimura S et al (1997) 18F-fluorodeoxyglucose positron emission tomography and the prognosis of patients with pancreatic adenocarcinoma. Cancer 79:695–699PubMedCrossRefGoogle Scholar
  38. 38.
    Nakata B, Nishimura S, Ishikawa T et al (2001) Prognostic predictive value of 18F-fluorodeoxyglucose positron emission tomography for patients with pancreatic cancer. Int J Oncol 19:53–58PubMedGoogle Scholar
  39. 39.
    Heinrich S, Schafer M, Weber A et al (2008) Neoadjuvant chemotherapy generates a significant tumor response in resectable pancreatic cancer without increasing morbidity: results of a prospective phase II trial. Ann Surg 248:1014–1022PubMedCrossRefGoogle Scholar
  40. 40.
    Smith IC, Welch AE, Hutcheon AW et al (2000) Positron emission tomography using [(18)F]-fluorodeoxy-d-glucose to predict the pathologic response of breast cancer to primary chemotherapy. J Clin Oncol 18:1676–1688PubMedGoogle Scholar
  41. 41.
    Katz MH, Fleming JB, Bhosale P, et al (2012) Response of borderline resectable pancreatic cancer to neoadjuvant therapy is not reflected by radiographic indicators. Cancer doi:  10.1002/cncr.27636. [Epub ahead of print]
  42. 42.
    Morgan DE, Waggoner CN, Canon CL et al (2010) Resectability of pancreatic adenocarcinoma in patients with locally advanced disease downstaged by preoperative therapy: a challenge for MDCT. AJR Am J Roentgenol 194:615–622PubMedCrossRefGoogle Scholar
  43. 43.
    Takahashi H, Ohigashi H, Ishikawa O et al (2012) Perineural invasion and lymph node involvement as indicators of surgical outcome and pattern of recurrence in the setting of preoperative gemcitabine-based chemoradiation therapy for resectable pancreatic cancer. Ann Surg 255:95–102PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Hirotada Kittaka
    • 1
  • Hidenori Takahashi
    • 1
  • Hiroaki Ohigashi
    • 1
  • Kunihito Gotoh
    • 1
  • Terumasa Yamada
    • 1
  • Yasuhiko Tomita
    • 2
  • Yoshihisa Hasegawa
    • 3
  • Masahiko Yano
    • 1
  • Osamu Ishikawa
    • 1
  1. 1.Department of SurgeryOsaka Medical Center for Cancer and Cardiovascular DiseasesOsakaJapan
  2. 2.Department of Pathology and CytologyOsaka Medical Center for Cancer and Cardiovascular DiseasesOsakaJapan
  3. 3.Morinomiya ClinicOsakaJapan

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