Positron emission tomography/computed tomography influences on the management of resectable pancreatic cancer and its cost-effectiveness

Abstract

Objective: We sought to determine the impact of positron emission tomography/computed tomography (PET/CT) on the management of presumed resectable pancreatic cancer and to assess the cost of this new staging procedure.

Summary background data: PET using 18F-fluorodeoxyglucose (FDG) is increasingly used for the staging of pancreatic cancer, but anatomic information is limited. Integrated PET/CT enables optimal anatomic delineation of PET findings and identification of FDG-negative lesions on computed tomography (CT) images and might improve preoperative staging.

Material and methods: Patients with suspected pancreatic cancer who had a PET/CT between June 2001 to April 2004 were entered into a prospective database. Routine staging included abdominal CT, chest x-ray, and CA 19-9 measurement. FDG-PET/CT was conducted according to a standardized protocol, and findings were confirmed by histology. Cost benefit analysis was performed based on charged cost of PET/CT and pancreatic resection and included the time frame of staging and surgery.

Results: Fifty-nine patients with a median age of 61 years (range, 40-80 years) were included in this analysis. Fifty-one patients had lesions in the head and 8 in the tail of the pancreas. The positive and negative predictive values for pancreatic cancer were 91% and 64%, respectively. PET/CT detected additional distant metastases in 5 and synchronous rectal cancer in 2 patients. PET/CT findings changed the management in 16% of patients with pancreatic cancer deemed resectable after routine staging (P = 0.031) and was cost saving.

Conclusions: PET/CT represents an important staging procedure prior to pancreatic resection for cancer, since it significantly improves patient selection and is cost-effective.

FIGURE 1. Transverse reconstruction of CT (A), PET (B), and PET/CT (C) of a 63-year-old female patient with cancer of the pancreatic tail. The metastasis in the abdominal wall (arrow) was missed on ceCT and only diagnosed because of its FDG uptake on PET/CT.

FIGURE 2. Coronal maximum intensity projection (MIP) image (A) and transverse PET, and PET/CT images at the levels of the neck (B, C) and clavicle (D, E) of a 36-year-old male patient. Pathologic FDG-uptake is found behind the left clavicle (arrows) and in the right neck (jugular chain, arrowheads). These lymph nodes were not palpable, but easily identified on transverse PET (B, D) and delineated on PET/CT (C, E) images.

FIGURE 3. Sagittal CT (A), PET (B), and coregistered PET/CT (C) images of a 76-year-old male patient. The images show FDG-positive cancer in the head of the pancreas (arrow). In addition, FDG uptake was detected in the upper rectum (arrowhead), which referred to synchronous rectal cancer.