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. 2024 Jul;25(7):644-655.
doi: 10.3348/kjr.2023.1235.

Predicting Recurrence-Free Survival After Upfront Surgery in Resectable Pancreatic Ductal Adenocarcinoma: A Preoperative Risk Score Based on CA 19-9, CT, and 18F-FDG PET/CT

Boryeong Jeong #  1 , Minyoung Oh #  2 , Seung Soo Lee  3 , Nayoung Kim  4 , Jae Seung Kim  2 , Woohyung Lee  5 , Song Cheol Kim  5 , Hyoung Jung Kim  1 , Jin Hee Kim  1 , Jae Ho Byun  1
Affiliations

Predicting Recurrence-Free Survival After Upfront Surgery in Resectable Pancreatic Ductal Adenocarcinoma: A Preoperative Risk Score Based on CA 19-9, CT, and 18F-FDG PET/CT

Boryeong Jeong et al. Korean J Radiol. 2024 Jul.

Abstract

Objective: To develop and validate a preoperative risk score incorporating carbohydrate antigen (CA) 19-9, CT, and fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT variables to predict recurrence-free survival (RFS) after upfront surgery in patients with resectable pancreatic ductal adenocarcinoma (PDAC).

Materials and methods: Patients with resectable PDAC who underwent upfront surgery between 2014 and 2017 (development set) or between 2018 and 2019 (test set) were retrospectively evaluated. In the development set, a risk-scoring system was developed using the multivariable Cox proportional hazards model, including variables associated with RFS. In the test set, the performance of the risk score was evaluated using the Harrell C-index and compared with that of the postoperative pathological tumor stage.

Results: A total of 529 patients, including 335 (198 male; mean age ± standard deviation, 64 ± 9 years) and 194 (103 male; mean age, 66 ± 9 years) patients in the development and test sets, respectively, were evaluated. The risk score included five variables predicting RFS: tumor size (hazard ratio [HR], 1.29 per 1 cm increment; P < 0.001), maximal standardized uptake values of tumor ≥ 5.2 (HR, 1.29; P = 0.06), suspicious regional lymph nodes (HR, 1.43; P = 0.02), possible distant metastasis on 18F-FDG PET/CT (HR, 2.32; P = 0.03), and CA 19-9 (HR, 1.02 per 100 U/mL increment; P = 0.002). In the test set, the risk score showed good performance in predicting RFS (C-index, 0.61), similar to that of the pathologic tumor stage (C-index, 0.64; P = 0.17).

Conclusion: The proposed risk score based on preoperative CA 19-9, CT, and 18F-FDG PET/CT variables may have clinical utility in selecting high-risk patients with resectable PDAC.

Keywords: 18F-FDG PET/CT; Carbohydrate antigen 19-9; Pancreatic ductal adenocarcinoma; Recurrence-free survival; Surgery.

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Conflict of interest statement

Seung Soo Lee, who holds the respective position of Editorial Board Member of the Korean Journal of Radiology, was not involved in the editorial evaluation or decision to publish this article. The remaining author has declared no conflicts of interest.

Figures

Fig. 1
Fig. 1. Flow diagram showing the study population. PDAC = pancreatic ductal adenocarcinoma, CA 19-9 = carbohydrate antigen 19-9, 18F-FDG = fluorine-18-fluorodeoxyglucose
Fig. 2
Fig. 2. Calibration plots of the risk score comparing predicted and observed risk of recurrence or death at one year in the development (A) and test (B) sets.
Fig. 3
Fig. 3. Recurrence-free survival and overall survival according to risk groups. A: Kaplan–Meier curves for the recurrence-free survival of the low-risk and high-risk groups in the test sets. B: Kaplan–Meier curves for the overall survival of the low-risk and high-risk groups in the test sets.
Fig. 4
Fig. 4. A 71-year-old female with PDAC was classified into the high-risk group. The pancreatic parenchymal phase of pancreatic protocol CT scan shows a 2-cm biopsy-proven PDAC (arrowheads) in the pancreas tail (A) with a SUVmax of 7.5 on 18F-FDG PET/CT (B). The CA 19-9 level was 3840 U/mL. The risk score for this patient was 4 points, with 1 point for tumor size, 1 point for SUVmax, and 2 points for CA 19-9 level, and she was classified into the high-risk group. The CT scan performed 2.5 months after pancreatic resection reveals metastasis in the liver (arrows) (C) and peri-splenic area (arrows) (D). PDAC = pancreatic ductal adenocarcinoma, SUVmax = maximum standardized uptake value, 18F-FDG = fluorine-18-fluorodeoxyglucose, CA 19-9 = carbohydrate antigen 19-9
Fig. 5
Fig. 5. A 64-year-old male with PDAC was classified into the low-risk group. The pancreatic parenchymal phase of pancreatic protocol CT shows 1.8 cm biopsy-proven PDAC (arrowheads) in the pancreas tail (A) with SUVmax of 2.7 on 18F-FDG PET/CT (B). The CA 19-9 level was 12 U/mL. No suspicious lymph node or distant metastasis was found on 18F-FDG PET/CT. The patient had a risk score of 0 points and was classified into the low-risk group. The patient remained recurrence-free until 40 months after upfront surgery. PDAC = pancreatic ductal adenocarcinoma, SUVmax = maximum standardized uptake value, 18F-FDG = fluorine-18-fluorodeoxyglucose, CA 19-9 = carbohydrate antigen 19-9
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