FDG-PET Predicts Neoadjuvant Therapy Response and Survival in Borderline Resectable/Locally Advanced Pancreatic Adenocarcinoma

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  • 1 Division of Hepatobiliary and Pancreas Surgery, Department of Surgery;
  • | 2 Division of Nuclear Medicine Radiology, Department of Radiology;
  • | 3 Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology;
  • | 4 Department of Radiation Oncology; and
  • | 5 Division of Medical Oncology, Department of Oncology, Mayo Clinic, Rochester, Minnesota.

Background: Neoadjuvant therapy (NAT) is used in borderline resectable/locally advanced (BR/LA) pancreatic ductal adenocarcinoma (PDAC). Anatomic imaging (CT/MRI) poorly predicts response, and biochemical (CA 19-9) markers are not useful (nonsecretors/nonelevated) in many patients. Pathologic response highly predicts survival post-NAT, but is only known postoperatively. Because metabolic imaging (FDG-PET) reveals primary tumor viability, this study aimed to evaluate our experience with preoperative FDG-PET in patients with BR/LA PDAC in predicting NAT response and survival. Methods: We reviewed all patients with resected BR/LA PDAC who underwent NAT with FDG-PET within 60 days of resection. Pre- and post-NAT metabolic (FDG-PET) and biochemical (CA 19-9) responses were dichotomized in addition to pathologic responses. We compared post-NAT metabolic and biochemical responses as preoperative predictors of pathologic responses and recurrence-free survival (RFS) and overall survival (OS). Results: We identified 202 eligible patients. Post-NAT, 58% of patients had optimization of CA 19-9 levels. Major metabolic and pathologic responses were present in 51% and 38% of patients, respectively. Median RFS and OS times were 21 and 48.7 months, respectively. Metabolic response was superior to biochemical response in predicting pathologic response (area under the curve, 0.86 vs 0.75; P<.001). Metabolic response was the only univariate preoperative predictor of OS (odds ratio, 0.25; 95% CI, 0.13–0.40), and was highly correlated (P=.001) with pathologic response as opposed to biochemical response alone. After multivariate adjustment, metabolic response was the single largest independent preoperative predictor (P<.001) for pathologic response (odds ratio, 43.2; 95% CI, 16.9–153.2), RFS (hazard ratio, 0.37; 95% CI, 0.2–0.6), and OS (hazard ratio, 0.21; 95% CI, 0.1–0.4). Conclusions: Among patients with post-NAT resected BR/LA PDAC, FDG-PET highly predicts pathologic response and survival, superior to biochemical responses alone. Given the poor ability of anatomic imaging or biochemical markers to assess NAT responses in these patients, FDG-PET is a preoperative metric of NAT efficacy, thereby allowing potential therapeutic alterations and surgical treatment decisions. We suggest that FDG-PET should be an adjunct and recommended modality during the NAT phase of care for these patients.

Submitted November 29, 2021; final revision received June 2, 2022; accepted for publication June 3, 2022.

Author contributions: Study concept and design: Abdelrahman, Truty. Data acquisition: Abdelrahman, Alva-Ruiz, Yonkus, Truty. Data analysis: Abdelrahman, Truty. Data interpretation: All authors. Writing – original draft: Abdelrahman, Truty. Writing – review and editing: All authors.

Disclosures: Dr. Halfdanarson has disclosed receiving grant/research support from Thermo Fisher Scientific, Turnstone Biologics, Advanced Accelerator Applications, Basilea, and Agios; and serving as an advisory board member for Terumo, Ipsen, Advanced Accelerator Applications, TerSera, ITM Isotopen Technologien Muenchen, Crinetics, and Viewpoint Molecular Targeting. The remaining authors have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Correspondence: Mark J. Truty, MD, MS, Division of Hepatobiliary and Pancreas Surgery, Department of Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902. Email: Truty.Mark@mayo.edu

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