pet ct evaluation of pancreatic neoplasms

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952 AJR:199 , November 2012

CMESAM

OBJECTIVE. Pancreatic cancer continues to have a poor prognosis despite impressive

improvements in the outcomes o many other types o cancer, oten because most pancreatic

neoplasms are ound to be unresectable at diagnosis. The purpose o this review is to provide

an overview o pancreatic cancer and the role o modern imaging in its diagnosis and man-

agement with an emphasis on 18F-FDG PET/CT usion imaging.

CONCLUSION. Multimodality imaging is critical in the diagnosis and management

o pancreatic cancer. PET/CT is increasingly viewed as a useul, accurate, and cost-eectivemodality in diagnosing and managing pancreatic cancer, but urther studies are warranted.

Early data suggest that contrast-enhanced PET/CT perormed with modern PET/CT scan-

ners yields high-resolution anatomic inormation or surgical and radiotherapeutic planning

and unctional inormation or whole-body staging in the care o patients with this disease.

Dibble et al.PET/CT o Pancreatic Neoplasms

Integrative ImagingReview

and ollow-up o many solid tumors in hu-

mans [513]. This review is an overview o

pancreatic neoplasms and o the role o mod-

ern imaging in the diagnosis and management

o pancreatic cancer with a ocus on PET/CT.

Pancreatic Neoplasm Overview

Classifcation

The major pancreatic neoplasms and their

key eatures are summarized in Table 1. Most

pancreatic neoplasms are exocrine, 85% being

invasive ductal adenocarcinoma [14]. Pancre-

atic neuroendocrine tumors, ormerly called is-

let cell tumors, constitute 34% o pancreatic

neoplasms [14] and are typically benign. Few-

er than 2% o malignant pancreatic neoplasms

originate rom endocrine cells [15]. The other

neoplasms are exocrine acinar cell neoplasms,

pancreatic cystic neoplasms, and neoplasms o

epithelial origin and o mixed dierentiation.

Presentation

Pancreatic cancer is oten asymptomatic in

the early stages. Patients may present with ob-

structive jaundice, weight loss, abdominal or

midback pain, or a combination o these symp-

toms [16]. Glucose intolerance also can be a sign

o pancreatic cancer [17]. Less common present-

ing symptoms o obstruction include pancreati-

tis and gastric outlet obstruction [16]. Asymp-

tomatic cancer can be detected incidentally

PET/CT of Cancer Patients: Part 1,Pancreatic Neoplasms

Elizabeth H. Dibble1

Dimitrios Karantanis2

Gustavo Mercier1

Patrick J. Peller3

Lisa A. Kachnic4

Rathan M. Subramaniam1,4,5

Dibble EH, Karantanis D, Mercier G, Peller PJ,

Kachnic LA, Subramaniam RM

1Department o Radiology, Boston University School o

Medicine, Boston, MA .

2Department o Molecular and Medical Pharmacology,

Ahmanson Biological Imaging Division, David Geen

School o Medicine at UCLA , Los Angeles, CA.

3Department o Radiology, Mayo Clinic, Rochester, MN.

4Department o Radiation Oncology, Boston University

School o Medicine, Boston, MA.

5Present address: Division o Nuclear Medicine, Russell H.

Morgan Department o Radiology and Radiologic Science,Johns Hopkins Medical Institutions, 601 N Caroline St, JHOC

3235, Baltimore, MD 21287. Address correspondence to

R. M. Subramaniam ([email protected]).

Integrative Imaging Review

CME/SAM

This article is available or CME/SAM credit.

AJR2012; 199:952967

0361803X/12/1995952

American Roentgen Ray Society

Pancreatic cancer is the 10th most

common cancer in the United

States but the ourth leading cause

o cancer death [1]. Despite ad-

vances in the detection and treatment o other

solid malignant tumors, pancreatic cancer

continues to have a dismal prognosisa

5-year survival rate o 6%because the tu-

mors are dicult to detect and are oten di-

agnosed late in their course. The only cure is

resection, but only 20% o patients present

with potentially resectable lesions [2]. Even

among patients with localized, resectable

disease, the survival rate is only 23% [1].

Thus early detection and appropriate selec-

tion o surgical candidates are critical to the

management o pancreatic cancer.

In addition to aiding selection o surgical

candidates, pancreatic cancer imaging helps

with characterization o incidentally ound

lesions, initial staging, surgical and radiother-apeutic planning, assessment o treatment re-

sponse, and monitoring or disease recurrence.

However, the selection o an imaging modality

or diagnosing and monitoring pancreatic can-

cers, particularly adenocarcinoma, is not uni-

orm. CT, transabdominal ultrasound, endo-

scopic ultrasound [3], ERCP, MRI, MRCP,

PET, and PET/CT [4] are all used in the im-

aging o these cancers. PET/CT is valuable in

the diagnosis, staging, therapeutic assessment,

Keywords: CT, MRI, pancreatic cancer, PET/CT

DOI:10.2214/AJR.11.8182

Received November 3, 2011; accepted ater revision

April 5, 2012.

R. M. Subramaniam was supported by a GE-AUR

research ellowship, a Siemens molecular imaging

research grant, and a Michael Fox Foundation research

grant.

FOCUSON:

PET/CT of Cancer Patients


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AJR:199 , November 2012 953

PET/CT of Pancreatic Neoplasms

on abdominal scans obtained or other reasons.

CT scans may depict pancreatic neoplasms

several months beore symptoms become

maniest [18]. Increasing use o imaging has

led to increased detection o pancreatic abnor-

malities, and approximately one third o pan-

creatic incidentalomas turn out to be malig-

nant [19, 20] (Fig. 1).Several rare paraneoplastic syndromes as-

sociated with pancreatic cancer have been

documented. Trousseau syndrome is a well-

established paraneoplastic syndrome associ-

ated with pancreatic adenocarcinoma that is

traditionally dened as migratory thrombo-

phlebitis but has more recently been broad-

ened to include other coagulopathies [21

23]. Pancreatic panniculitis, or subcutaneous

areas o nodular at necrosis, is also associ-

ated with pancreatic cancer. Eighty percent

o cases o panniculitis related to pancreatic

cancer are associated with acinar cell carci-

noma. Panniculitis usually involves the low-

er extremities but also occurs in the buttocks,

trunk, and arms [24]. Other interesting para-

neoplastic or paraneoplastic-like presenting

signs o pancreatic cancer documented at

least once include lower leg asciitis associ-

ated with panniculitis [25], eczematous der-

matitis [26], brous cutaneous hand changes

[27], and plantar keratoderma [28].

Pancreatic neuroendocrine tumors present

most commonly with abdominal pain; ewer

than one hal o cases present with endocrine

disturbances [29]. Actively secreting neuro-

endocrine tumors that do cause endocrinedisturbances include gastrinoma, which can

cause Zollinger-Ellison syndrome; insulino-

ma, which can cause hypoglycemia; gluca-

gonoma, which can cause diabetes mellitus

and is also associated with necrolytic migra-

tory erythema; vasoactive intestinal poly-

peptide tumor (VIPoma), which can cause

watery diarrhea and its associated complica-

tions; and somatostatinoma, which is asso-

ciated with an elevated blood glucose con-

centration and diarrhea [30]. There are case

reports o corticotropin-secreting pancre-

atic neuroendocrine tumors causing Cush-

ing syndrome [31, 32]. More than one halo all neuroendocrine tumors are carcinoid

neoplasms [33], but these neoplasms are

very rare in the pancreas [34]. The syndrome

they cause is notable or diarrhea and fush-

ing [34]. Hypercalcemia related to parathy-

roid hormonerelated peptide (PTHrP) has

been reported in a PTHrP-producing neuro-

endocrine tumor [35], among other extreme-

ly rare pancreatic neuroendocrine tumors.

Role of Multimodality Imaging

in Initial Management

The major goals o imaging in the initial

management o pancreatic neoplasms are to

characterize incidentally ound lesions, as-

sist with staging o pancreatic cancer, and

assist with surgical and radiotherapeutic

planning. CT is the best-validated and mostwidely available modality or diagnosis and

initial management, but MRI, MRCP, trans-

abdominal ultrasound, endoscopic ultra-

sound, ERCP, PET, and PET/CT have all

been used (Table 2). The National Compre-

hensive Cancer Network (NCCN) provides

guidelines or the imaging o pancreatic ad-

enocarcinoma in which CT or MRI is recom-

mended or evaluation o patients in whom

pancreatic cancer or ductal dilation is clin-

ically suspected [36]. The NCCN similarly

recommends multiphasic CT or MRI to eval-

uate suspected pancreatic neuroendocrinetumors [37]. The American College o Ra-

diology appropriateness criteria or selecting

imaging studies are guidelines or imaging

o patients with painless jaundice and pal-

pable abdominal masses, again with CT as

the most appropriate modality [38, 39]. In

numerous studies in recent years, investiga-

tors have dened and compared the accura-

cy o various imaging modalities and tech-

niques and elucidated areas where imaging

data are inadequate. This section summariz-

es current imaging modalities in the initial

management o pancreatic neoplasms with a

ocus on techniques not discussed in depth inthe aorementioned established guidelines.

Triple-Phase Pancreatic PET/CT Protocol

The triple-phase enhanced pancreatic PET/

CT protocol (Fig. 2) is perormed at our in-

stitution. The patient is given an injection o

10 mCi 18F-FDG and waits 60 minutes. Thir-

ty minutes ater injection o FDG, the patient

drinks 450 mL o oral contrast barium prep-

aration (VoLumen, E-Z-EM). The patient is

scanned rom skull base to midthigh accord-

ing to a routine PET/CT protocol with low-

dose attenuation-correction CT. CT is then

perormed in three phases with diagnosticparameters and contrast administration. The

rst, unenhanced, phase is a deep-inspiration

scan o the lower chest and abdomen with

the ollowing parameters: 120 kV; automatic

tube current, 150440 mA; slice thickness,

1.25 mm; pitch, 1.375. The second, arterial,

phase is a scan o the same area 45 seconds

ater IV injection o 70 mL o ioversol (Op-

tiray, Mallinckrodt Imaging). The third, ve-

nous, phase is a scan o the same area 70 sec-

onds ater contrast injection. Hybrid PET/CT

images are generated by usion o the PET

and triple-phase CT images.

Dierentiating Benign From

Malignant Disease

Multimodality imaging can help charac-terize lesions as benign or malignant beore

or, in some benign cases, without tissue di-

agnosis. The pancreatic CT protocol or eval-

uation o suspected pancreatic cancer at our

institution includes thin-slice MDCT in the

unenhanced, arterial, and venous phases (Fig.

2). MRI is an acceptable alternative when pa-

tients cannot undergo CT. ERCP, endoscopic

ultrasound, and MRCP are useul as adjunct

modalities and when CT or MRI reveals duc-

tal stricture but no tumor [36]. The NCCN

does not provide specic recommendations

regarding PET/CT, except to state that at

this time PET/CT is not a substitute or high-

quality contrast-enhanced CT because its role

is still being established [36]. Although the

technology exists or combining diagnostic-

quality CT scans and PET images, imaging

protocols are still being standardized [4].

One o the earliest uses o pancreatic PET

was to dierentiate chronic pancreatitis rom

pancreatic cancer; diuse versus ocal uptake

is the dierentiating characteristic in this clini-

cal scenario [40] (Figs. 3 and 4). An early tab-

ulated summary o FDG PET literature [41]

showed a 50% change in management eect

based on 26 patient studies o the use o PETor the diagnosis o pancreatic cancer in all

scenarios with a weighted average sensitivi-

ty and specicity o 94% and 90% compared

with 82% and 75% or CT at that time. In an

early use o usion PET/CT, Lemke et al. [42]

ound that using triple-phase MDCT with

PET images improved the sensitivity o dier-

entiating benign and malignant lesions with-

out a signicant change in specicity. PET/CT

and MRI can be helpul in detecting pancre-

atic adenocarcinoma in patients with visually

isoattenuating lesions at CT [43]. Pancreatic

cancer can be dierentiated rom autoimmune

pancreatitis with PET/CT [44, 45], potentiallysparing patients unnecessary surgery. Signi-

cantly dierent standardized uptake values at

PET/CT have been reported in malignant in-

traductal papillary mucinous neoplasms com-

pared with benign lesions [46].

In a meta-analysis o 51 studies [47], PET,

PET/CT, and endoscopic ultrasound were com-

pared or useulness in the diagnosis o all pan-

creatic carcinomas. The investigators ound


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Dibble et al.

By dierentiating contrast-enhanced and un-

enhanced PET/CT, the most recent study

[51] showed a problem in summarizing the

PET/CT literature: Many study reports are

unclear about whether contrast material was

used uniormly or at all. Contrast-enhanced

imaging is expected to improve the CT com-

ponent o PET/CT, resulting in superior im-ages; however, use o contrast enhancement

requires additional expertise by technical

sta and by scan readers (Figs. 58).

MRI is an accepted modality or imaging o

patients with suspected pancreatic cancer, and

MRCP is accurate in the diagnosis o biliary

stones and strictures. Like ERCP, MRCP is

especially useul when a mass is not seen with

other imaging modalities but ductal stricture

is suspected or known. As a sole technique

or diagnosing pancreatic malignancy, MRCP

is similar to ERCP with only 84% sensitivity

and 94% specicity, according to a 2003 me-

ta-analysis [52]. In a relatively new use, diu-

sion-weighted MRI (DWI) has been studied as

an additional technique to help dierentiate be-

nign rom malignant disease. Muhi et al. [53]

reported that DWI had sensitivity and specic-

ity o 96.2 and 98.6 in the detection o pancre-

atic carcinoma by three blinded radiologists.

Autoimmune pancreatitis can be dierentiat-

ed rom pancreatic cancer with DWI [45], and

signicant dierences in the apparent diusion

coecients o chronic pancreatitis and pancre-

atic carcinoma have been ound [54].

Cystic LesionsIncidentally ound cystic lesions o the pan-

creas are a common clinical problem and pres-

ent a particular challenge in dierentiating be-

nign rom malignant disease. These cysts are

ound on approximately 2.3% o CT studies

and as many as 19% o MRI studies [55]. Gas-

troenterology societies, pancreatology groups,

and radiology groups all publish guidelines or

the management o pancreatic cysts [5658].

Despite the American College o Radiology

consensus publication [58] on the management

o incidentally ound asymptomatic pancreatic

cysts, there remains considerable variability in

radiologists recommendations or ollow-upimaging [59, 60]. This dierence may be due in

part to the availability o and experience with

various imaging modalities not included in the

American College o Radiology guidelines. In

addition, ewer studies have validated their

use, although these alternative imaging mo-

dalities and techniques may eventually limit

the need or the serial ollow-up imaging that

is currently recommended [61].

overall pooled sensitivities o 88.4%, 90.1%,

and 81.2% and overall pooled specicities o

83.1%, 80.1%, and 93.2% or the three tech-

niques. Endoscopic ultrasound had the most

heterogeneity in study results and was less

helpul in the diagnosis o cancer in patients

with a history o chronic pancreatitis. To our

knowledge, in only our prospective studies

[4851] has the useulness o PET/CT in the

diagnosis o pancreatic cancer been exam-

ined (Table 3). Two o the reports [48, 50]

noted that management was changed and cost

saved with PET/CT in certain circumstances,

as in the discovery o second primary lesions.

TABLE 1: Major Pancreatic Neoplasms and Their Key Features

Neoplasm Features

Exocrine neoplasms

Invasive ductal adenocarcinomas Prevalence greater in male than emale pat ients

Head and tail equally aected

Symptoms are jaundice and weight loss

85% o all pancreatic neoplasms

Acinar cell neoplasms Prevalence greater in male than emale patients



Pancreatic cystic neoplasmsSerous cystic neoplasm Prevalence greater in emale than male patients



True cystic neoplasm

Mucinous cystic neoplasm Prevalence dramatically greater in emale than malepatients

Tail only


True cystic neoplasm

Intrapapil lary mucinous neoplasms Prevalence greater in men than women

Head involved more oten than tail

Exocrine insufciency, pain


Intraductal cystic neoplasm

Epithelial and mixed dierentiat ion neoplasms

Solid-pseudopapillary neoplasm Prevalence markedly greater in emale than malepatients


Degenerative papillary cystic neoplasm, both solidand cystic


Epithelial origin

Pancreatoblastoma Prevalence greater in boys than girls


Found primarily in children

< 1% o all pancreatic neoplasms

Neuroendocrine tumors Similar prevalence in male and emale patients


Endocrine paraneoplastic syndromes

3 4% o all pancreatic neoplasms


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Certain characteristics o cystic lesions help

distinguish them as benign versus malignant,

such as mural nodules, mural irregularity, pe-

ripheral calcications, and surrounding sot-

tissue nonuniormity relative to the rest o the

pancreas. PET/CT has been ound compara-

ble or superior to PET or CT alone in deter-

mining the presence o malignancy in cysticpancreatic lesions [62] (Fig. 9). In one study

[63], PET/CT ndings led to modication o

the initial management strategy or one o ve

patients with cystic pancreatic neoplasms.

False-positive ndings, however, have been

problematic in the imaging o cystic tumors

[64]. DWI also has been used to help char-

acterize cystic lesions o the pancreas. Wang

et al. [65] ound it dicult to dierentiate in-

fammatory and neoplastic lesions (both solid

and cystic) because o an overlap in apparent

diusion coecients. In contrast, Takakura

et al. [66] reported no signicant dierence

in cancer detection between DWI and the rec-

ommended MDCT (84% versus 86%) and

noted that MRI with MRCP and DWI allows

characterization with a single modality with-

out contrast administration.

Staging and Surgical Planning

CT, MRI, PET, PET/CT, and laparoscop-

ic and open surgery have all been used or

staging pancreatic cancer. CT is the best-

validated modality and has been the reer-

ence standard or assessing locoregional and

nodal tumor involvement at or ater diagno-

sis. The pancreatic CT protocol o triphasiccross-sectional imaging and use o thin slic-

es allows assessment o resectability and vis-

ualization o important vessels and anatomic

relationships (Fig. 10). MRI is an acceptable

alternative when patients cannot undergo

CT, but it should not be considered an alter-

native to MDCT, when MDCT is possible,

according to NCCN guidelines [36]. A 2009

study [67] comparing gadolinium-enhanced

3D gradient-echo MRCP and MDCT showed

similar utility o the two methods in determi-

nation o resectability.

In terms o the util ity o PET, a 2001 anal-

ysis o 33 early PET studies [41] showed acombined 36% change in management eect

when PET was used or initial staging. Con-

trast-enhanced PET/CT combines metabol-

ic and anatomic inormation, and the nd-

ings can alter management strategy through

prevention o unnecessary laparotomy. In a

2008 study [68], contrast-enhanced PET/CT

was signicantly superior to PET alone or

the preoperative assessment o cancer resect-

ability. PET and PET/CT both had sensitivi-

ties o 100%, but PET alone had a specicity

o 44%, whereas PET/CT had 56% specic-

ity. Contrast-enhanced PET/CT was superior

to unenhanced PET/CT with a sensitivity o

96% and a specicity o 82%. A small num-

ber o patients still had unresectable tumors

that were missed with all imaging meth-

ods and were diagnosed intraoperatively. In

a 2009 study [50], the investigators com-

pared PET/CT, MDCT, and MRI/MRCP and

ound that PET/CT had higher diagnostic ac-

curacy than other methods, was more sensi-

tive in the diagnosis o primary pancreatic

malignancy and metastasis, and had ndings

that changed the management strategy in 10

o 38 cases. However, PET/CT was less sen-sitive than the other imaging modalities in

the diagnosis o lymph node involvement.

Value of FDG PET/CT in the

Planning of Radiotherapy for

Pancreatic Cancer

Resection is the only curative treatment o

pancreatic cancer, and optimal adjuvant and

neoadjuvant radiotherapeutic approaches re-

main controversial [6972]. Patients with le-

sions deemed borderline resectable may be

able to undergo resection ater chemotherapy,

radiotherapy, or both [73]. PET/CT has been

suggested as potentially useul in delineatingthe gross tumor volume or radiotherapeutic

planning (Fig. 11). Accurately dening gross

tumor volume is critical given the risk to nor-

mal surrounding tissue (kidney, small bow-

el, liver, spinal cord, and stomach) during ra-

diotherapy and the potential or missing the

tumor in a conormal radiation eld. Ford et

al. [64] reviewed the role o PET/CT in ra-

diotherapeutic planning and noted improved

delineation o tumor margins compared with

that achieved with CT alone. Similarly, a sin-

gle-institution study o CT versus PET/CT in

the care o 14 patients undergoing radiation

planning or unresectable disease showed

that the addition o PET resulted in an av-

erage 30% increase in gross tumor volume

in ve patients owing to the incorporation

o additional lymph node metastatic lesions

and extension o the primary tumor beyond

the volume dened with CT [74]. Although

radiotherapy may improve local control and

resectability rates or pancreatic cancer and

PET/CT has been suggested to be useul in

conormal treatment planning, improvements

in overall survival with optimized radiation

therapy remain to be determined.

Value of FDG PET/CT in Prognosis

and Management Strategy

PET and PET/CT ndings may play a role

in prognosis, assessment o treatment re-

sponse, and monitoring or cancer recurrence.

Schellenberg et al. [75] ound that or locally

advanced unresectable pancreatic neoplasms,

standardized uptake values rom pretreatment

PET/CT scans were prognostic o overall and

progression-ree survival even with control

or age, presenting CA19-9 result, and single

versus combination chemotherapy. Early PET

studies showed that PET ndings are predictiveo histologic response ater treatment o pan-

creatic cancer and that PET shows a decrease

in metabolism ater intraoperative radiothera-

py or unresectable pancreatic cancer earlier

than CT does. Thus the tumor response can

be evaluated earlier and more accurately with

PET than with CT [7679]. PET may also be

more accurate than CT in evaluating treatment

response and prognosis [80]. Kuwatani et al.

TABLE 2: Advantages and Limitations of Pancreatic Cancer ImagingTechniques

Modality Advantages Limitations

MRI Depiction o evidence o localextrapancreatic disease

Contraindicated with some metal implantsand ragments

Radiation ree High cost

MRCP Useul or evaluating biliary obstruction Contraindicated with some metal implantsand ragments

Radiation ree High cost

CT Widely available Radiation and contrast exposure

Best validated Limited useulness in evaluation o smallmetastatic lesions

PET/CT Depicts evidence o metastatic disease Radiation and contrast exposure

Clar ifcat ion o equivocal CT fndings High cost


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Dibble et al.

[81] ound that PET beore and ater chemo-

therapy could be used to estimate chemothera-

peutic eect and predict survival. A 2011 re-

view o the role o FDG PET/CT in imaging

o recurrent pancreatic carcinoma [82] showed

that PET/CT improves evaluation o cancer

recurrence in general and that, in particular,

it improves evaluation o patients with elevat-

ed concentrations o tumor markers (CA19-9)

and those with normal or equivocal CT nd-

ings (Fig. 12).

Cost-Effectiveness of FDG

PET/CT in the Management

of Pancreatic Cancer

Cost-eectiveness is a critical actor in de-

termining the optimal imaging modality. In

2006, the most cost-eective and accurate

means or diagnosing and staging pancreatic

cancer were CT and endoscopic ultrasound

[2]. This nding was based on the high cost

o MRI, the limited available data on con-

trast-enhanced PET/CT, and the lack o evi-

dence o the superiority o these modalities

to the less expensive CT and endoscopic ul-trasound. More recently, however, PET/CT

has been recognized as a possible cost-sav-

ing imaging modality. Findings at PET and

PET/CT or many indications, not only or

pancreatic cancer, have been ound to change

management strategy [83], and although

PET/CT has a high initial cost, it has the po-

tential to reduce total imaging costs owing to

its superior depiction o distant metastatic le-

sions, preventing surgery and reducing can-

cer imaging costs in aggregate.

Heinrich et al. [48] have been one o only

a ew groups o investigators to examine the

cost-eectiveness o PET/CT. They oundthat or imaging pancreatic adenocarcinoma,

PET/CT was more sensitive than conventional

CT or detecting distant metastasis and that the

ndings changed the management plans or

16% o patients with lesions deemed resecta-

ble ater conventional staging. The cost-bene-

t analysis included the price o PET/CT, the

radiotracer, ne-needle aspiration biopsy, cy-

tologic analysis, ultrasound, CT, thoracosco-

py, and pancreatic resection, including phy-

sician ees and postoperative stay (based on

costs at the authors institution or a 15-day

postoperative stay based on range o 1040

days). PET/CT was reported to save an aver-

age o $62,912 or all 59 patients included in

the study, or $1066 per patient. The authors

urther determined that limiting PET/CT to

patients with lesions deemed resectable at

conventional imaging would save $2844 per

patient, that limiting the postoperative hospital

stay to 10 days led to a savings o $430 per

patient, and that using CT-guided ne-needle

aspiration rather than ultrasound-guided ne-

needle aspiration to conrm each distant meta-

static site would still save $341 per patient.

The study methods have been criticized, espe-

cially with regard to the anatomic eld o CT

and a lack o preresection laparoscopic ex-

ploration cost analysis [84], but the cost anal-

ysis was based on an actual standard staging

protocol and resultant procedures, not theo-

retic scenarios, as the authors noted in a reply

[85]. In a systematic review o the cost-eec-

tiveness o the use o PET and PET/CT or alldiagnoses compared with other imaging tech-

niques and interventions, Langer [86]. con-

curred that PET may be cost-eective and

that PET/CT may be more cost-eective than

PET, although only our studies analyzing

the cost-eectiveness o PET/CT have been

published. Future large prospective studies

are still warranted, especially with contrast-

enhanced PET/CT.

An example o the cost-eectiveness o

PET/CT occurred at our institution in 2011.

A 59-year-old woman was treated or pancre-

atic cancer ound incidentally on a CT scan.

Posttreatment PET/CT (Figs. 12A and 12B)showed mild FDG uptake in the sot tissue

adjacent to the let kidney that was suspi-

cious or metastatic disease. Two ollow-up

CT examinations were perormed to monitor

the lesion and to detect recurrence o disease,

but the ndings were equivocal. Follow-up

PET/CT several months later (Figs. 12C

12G) conrmed the presence o an enlarging

perinephric metastatic lesion and new liver

lesions. The disease progression in this pa-

tient likely would have been conrmed ear-

lier with PET/CT, and the patient would have

been saved the expense o two noncontribu-

tory interval CT scans.

Conclusion

Numerous imaging modalities are usedor the diagnosis and management o pancre-

atic cancer. The best-validated uses o PET

and PET/CT are initial staging and treatment

planning. Given the poor prognosis and lim-

ited treatment options or pancreatic cancer,

the greatest potential benet is gained dur-

ing this time rame. Data on the useulness o

PET and PET/CT in surgical and radiothera-

peutic planning, or monitoring or treatment

response and recurrent disease, and on cost-

eectiveness are somewhat more limited and

require urther study. Multimodality imaging

is critical in the diagnosis and management o

pancreatic cancer. As the spatial resolution o

PET/CT continues to improve with the devel-

opment o 16- and 64-MDCT PET/CT sys-

tems and the increasing use o contrast mate-

rial, contrast-enhanced PET/CT may become

the imaging test o choice in the management

o pancreatic cancer, and as such continued

prospective evaluation is warranted.

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cier G, Subramaniam RM. Value o PET/CT in

the management o liver metastases, part 1.AJR

2011; 197:365; [web]W256W259

TABLE 3: Prospective Studies of PET/CT in the Diagnosis of Pancreatic Cancer

Author Year nSensitivity

(%)Specifcity

(%)Positive Predictive

Value (%)Negative Predictive

Value (%)

Heinrich et al. [48] 2005 59 89 69 91 64

Schick et al. [49] 2008 46 89 74 83 82

Kauhanen et al. [50] 2009 38 85 94 94 85

Buchs et al. [51] 2011 42 87.9 55.6 87.9 55.6


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Serv Res 2010; 10:283


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Fig. 177-year-old man with incidental fnding o pancreatic lesion at routine 2-year imaging ollow-up olaryngeal cancer.A and B, Coronal maximum-intensity-projection (A) and axial (B) PET images show increased uptake in area opancreas (arrow, B).C and D, Axial CT (C) and corresponding PET/CT (D) images show 2-cm poorly marginated low-attenuationmass at junction o body and tail o pancreas wi th moderate FDG uptake (arrow, D). Distal pancreas and spleenresection yielded pancreatic ductal carcinoma and multiple negative peripancreatic lymph nodes.


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Dibble et al.

Fig. 255-year-old man with pancreatic adenocarcinoma.AF, Unenhanced (A), arterial (C), and venous (E) phase CT images and corresponding used FDG PET/CT (B, D,and F) images show appearance during triple-phase contrast-enhanced pancreatic PET/CT protocol.


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Fig. 367-year-old man with jaundice and vague abdominal pain due to autoimmune pancreatitis. ERCP

revealed diuse irregular narrowing o main pancreatic duct.A and B, Coronal maximum-intensity-projection (A) and axial PET (B) images show moderate diuse increasedFDG accumulation in pancreas (percutaneous drainage tube is presen t in common bile duct and passes tooutside drainage bag).C, Axial CT image shows diusely enlarged pancreas and mild prominence in pancreatic head with distinctmass ormation.D, Fused axial PET/CT image shows relatively homogeneous increased activity throughout pancreas (maximumstandardized uptake value, 5.1). Serum assays revealed elevated antinuclear antibody, rheumatoid actor, andantilactoerrin antibody levels. Treatment with corticosteroids produced prompt remission.


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Dibble et al.

Fig. 462-year-old man undergoing chemotherapy or metastatic lung cancer with idiopathic pancreatitiscausing severe upper abdominal pain that radiates to back. ERCP showed diuse irregular narrowing o main

pancreatic duct without site o obstruction. Metastatic nodes were present adjacent to pancreatic head.A and B, Coronal maximum-intensity-projection (A) and axial PET (B) images show moderate diuse increasedFDG accumulation in pancreas.C, Axial CT scan shows diusely enlarged pancreas.D, Axial used PET/CT scan shows moderate diuse increased FDG accumulation and enlarged pancreas.Symptoms resolved with supportive treatment.


12/16



Fig. 552-year-old woman with hypoglycemic episodes and increasing back pain and history glucagon-secreting pancreatic neuroendocrine tumor treated withresection o primary tumor and let hepatic lobe.AC , Coronal maximum-intensity-projection (A), axial PET (B), and used axial PET/CT (C) images show 2.5-cm mass in head o pancreas with mild FDG uptake (arrow, C).D, Axial CT scan shows hypoenhancing pancreatic head lesion.E, T1-weighted at-suppressed MR image shows lesion.F, Octreotide SPECT/CT scan shows intense 111In-octreotide accumulation in pancreatic head mass (arrow).G, T1-weighted at-suppressed contrast-enhanced MR image shows hyperenhancing pancreatic head mass (arrow). Biopsy confrmed recurrent glucagon-secretingpancreatic neuroendocrine tumor.


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Dibble et al.

Fig. 772-year-old man with pancreatic lymphoma, epigastric discomort, and atigue. Upper gastrointestinal endoscopic fndings were normal.AC, Coronal maximum-intensity-projection (A) and axial PET (B and C) images show intense FDG uptake in pancreas.D and E, Axial CT images show 2.5-cm hypoenhancing pancreatic mass (arrow, D) and spleen or PET/CT comparison.F and G, Axial used PET/CT images show 2.5-cm uncinate mass with intense FDG uptake (maximum standardized uptake value, 8.9) and moderate diuse activity inspleen (arrow, G) that suggested lymphoma. Fine-needle aspiration o pancreatic mass and bone marrow biopsy yielded ollicular non-Hodgkin lymphoma.

Fig. 664-year-old woman with pancreatic adenocarcinoma, acholic stools, and jaundice.A, T2-weighted selective partial inversion recovery MR image shows pancreatic head mass (arrow) with obstruction.B, Axial contrast-enhanced CT image shows heterogeneously enhancing necrotic solid mass (arrow) in pancreatic head.C, Axial contrast-enhanced used PET/CT image shows intense hypermetabolic activity (arrow) corresponding to mass in B.


14/16



Fig. 870-year-old man with history o hairy cell leukemia initially diagnosed 4 years earlier and treated with

splenectomy and chemotherapy. Follow-up CT showed 3.2 2.7 cm mass in body o pancreas.A, Coronal maximum-intensity-projection image shows moderate diuse activity in bone marrow o axial andproximal appendicular skeleton.B, Axial PET image shows increased uptake in pancreatic head (arrow).C and D, Axial CT (C) and corresponding PET/CT (D) images show 3.2-cm mass (arrow, D) in head o pancreaswith moderate FDG uptake (maximum standardized uptake value, 5.0). Pancreatic mass and bone marrowbiopsies confrmed diagnosis o recurrent hairy cell leukemia.


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Dibble et al.

Fig. 946-year-old man with abdominal pain due to pancreatic adenocarcinoma.AD, Coronal maximum-intensity-projection (A), coronal contrast-enhanced used PET/CT (B), and axial contrast-enhanced used PET/CT (C and D) images showhypermetabolic activity and mass (arrow, C and D) in head and neck o pancreas without evidence o metastatic disease. Biliary s tent is in place.E and F, Axial contrast-enhanced CT images show cystic lesion (arrow, F). Cystic areas are likely pseudocysts.

Fig. 1058-year-old man with 6 weeks o painless jaundice; ultrasound showed pancreatic abnormality.A and B, Coronal arterial (A) and venous (B) phase CT images show heterogeneously enhancing mass (bluearrow, A) in head o pancreas encasing hepatic artery and dilatation o common bile (yellow arrow,A) andpancreatic (red arrow,A) ducts.

Fig. 1162-year-old man with known inoperable T2N0M0 adenocarcinoma o the pancreas undergoing stagingscanning or radiotherapeutic planning.A, Axial CT image shows head o pancreas with indwelling stent.B, Same axial slice as A used with FDG PET scan obtained or staging. PET enables radiation oncologist tomore easily discern gross tumor volume (inner outline), or which 50 Gy in 25 daily ract ions is prescribed,whereas clinical target volume (outer outline) encompassing locoregional nodal basins receives 45 Gy in 25ractions through dose painted intensity-modulated technique.


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Fig. 1259-year-old woman with history o pancreatic adenocarcinoma ound incidentally on CT scan.A and B, Contrast-enhanced axial CT (A) and contrast-enhanced axial used PET/CT (B) images obtained immediately ater therapy show mild FDG uptake in sot tissueadjacent to let kidney (arrow,B) that was suspicious or metastatic disease.

CG, Follow-up coronal maximum-intensity-projection (C), axial contrast-enhanced CT (D and E), and axial contrast-enhanced used PET/CT images (F and G) scansobtained several months ater A and B confrm presence o enlarging perinephric metastatic lesion and new liver lesion (arrows,F and G). Two interval CT scans between

the PET/CT scans were noncontributor y.

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pet ct evaluation of pancreatic neoplasms