International multicenter validation of an 18F-fluorodeoxyglucose positron emission tomography/computed tomography maximum standardized uptake value 4.0 threshold to guide surgical selection in pancreatic ductal adenocarcinoma following neoadjuvant therapy
In brief
High PET uptake plus elevated tumor marker marked 32% early recurrence
In 923 patients who had surgery after preoperative treatment for pancreatic cancer, PET uptake of at least 4 combined with an elevated CA 19-9 level identified a subgroup in which 32% had recurrence within six months. The threshold also tracked with worse survival in an independent cohort, but the combination missed many early recurrences, so its role in guiding surgery remains to be established.
- Journal
- Surgery (Q1)
- Published
- 3 August 2026
- Study design
- Retrospective cohort
- Evidence level
- Level 3, Low (CEBM 3b)
- Authors
- Naoki Ikenaga, Hyung Sun Kim, Shingo Baba, Yoon Soo Chae, Wooil Kwon, Jin-Young Jang, et al.
- PMID
- 42957525
- DOI
- 10.1016/j.surg.2026.110503
Why clinicians should know about it
- Picked for Surgical Oncology (paper of the day, 2 November 2026): Post-neoadjuvant PET may guide pancreatic resection selection
Abstract
BACKGROUND: To determine whether a single post-neoadjuvant therapy fluorodeoxyglucose positron emission tomography combined with computed tomography measurement and maximum standardized uptake value can guide surgical selection in anatomically resectable or borderline-resectable pancreatic ductal adenocarcinoma. Limitations of morphologic computed tomography because of neoadjuvant therapy-induced changes require decision-time biomarkers reflecting residual tumor biology. METHODS: This international multicenter retrospective study analyzed 923 patients with resectable or borderline-resectable pancreatic ductal adenocarcinoma who underwent neoadjuvant therapy, preoperative fluorodeoxyglucose positron emission tomography combined with computed tomography, and pancreatectomy. An outcome-based post-neoadjuvant therapy maximum standardized uptake value threshold of 4.0 was derived from a temporal derivation cohort (2017-2019; n = 413) and validated without reoptimization in an independent cohort (2020-2021; n = 510). The end points were overall survival, recurrence-free survival, early recurrence within 6 months, and first-failure pattern. RESULTS: Post-neoadjuvant therapy maximum standardized uptake value ≥4.0 was independently associated with inferior overall survival (derivation: hazard ratio, 1.86; 95% confidence interval, 1.40-2.45; validation: hazard ratio, 1.53; 95% confidence interval, 1.13-2.07). Combining maximum standardized uptake value (≥4.0 vs <4.0) with post-neoadjuvant therapy carbohydrate antigen 19-9 (>37 vs ≤37 U/mL) yielded clear stepwise separation of recurrence-free survival and overall survival. Maximum standardized uptake value ≥4.0 modestly predicted early recurrence within 6 months (area under the curve, 0.65), whereas a "double-positive" rule (maximum standardized uptake value ≥4.0 and carbohydrate antigen 19-9 >37 U/mL) increased specificity (0.83) with lower sensitivity (0.42), with 32% early recurrence within 6 months in this subgroup. A high maximum standardized uptake value was associated with distant but not margin-related failure. CONCLUSION: A post-neoadjuvant therapy maximum standardized uptake value threshold of 4.0 defined a reproducible, single-time-point metabolic criterion that complemented carbohydrate antigen 19-9 level to enable biology-guided surgical selection in anatomically resectable pancreatic ductal adenocarcinoma.
Abstract as published, via PubMed.
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