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Differentiating benign and malignant pancreatic masses: Ga-68 PSMA PET/CT as a new diagnostic avenue

  • Nuclear Medicine
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objective

Differentiation of malignant and benign pancreatic lesions on anatomical imaging is difficult in some cases with overlapping features. Prostate-specific membrane antigen (PSMA) is overexpressed during angioneogenesis in many tumors. We aimed to evaluate the PSMA expression in pancreatic lesions to differentiate these lesions and explore the performance of Ga-68 PSMA-PET/CT vis-a-vis F-18 FDG-PET/CT.

Methods

Patients with pancreatic lesions on conventional imaging were prospectively recruited. All the patients underwent a whole-body F-18 FDG-PET/CT and a regional abdominal Ga-68 PSMA-PET/CT. Focal tracer uptake (FDG or PSMA) on PET images was considered positive. Histopathology and/or cytopathology were considered the reference standard.

Results

A total of forty patients (27 males, mean age 55.3 ± 9.8, range 37–71 years) were enrolled. Of these, 19 were diagnosed as malignant on histopathology/cytology. Patients with benign lesions showed no worsening of symptoms for at least 6 months on follow-up. FDG-PET/CT revealed 17 true-positive (TP), 9 false-positive (FP), 12 true-negative (TN), and 2 false-negative (FN) findings, whereas PSMA-PET/CT had 18 TP, 2 FP, 19 TN, and 1 FN finding. The sensitivity, specificity, PPV, NPV, and accuracy for FDG-PET/CT were 89.5%, 57.1%, 65.4%, 85.7%, and 72.5%, respectively, while for PSMA-PET/CT were 94.7%, 90.5%, 90%, 95%, and 92.5%, respectively. ROC curve analysis showed that the SUVmax value of 4.8 on PSMA-PET/CT could predict the malignant potential of a lesion with a specificity of 90.5% and a sensitivity of 84.2%.

Conclusions

Ga-68 PSMA-PET/CT imaging helped in establishing a non-invasive pre-operative diagnosis of primary pancreatic malignancy with a higher degree of specificity and accuracy compared with FDG-PET/CT.

Key Points

• Conventional imaging such as CT and MRI are unable to reliably differentiate localized malignant pancreatic lesion from benign lesions mimicking malignancy such as mass-forming pancreatitis.

• FDG PET/CT helps in detecting malignant foci in view of their increased glucose metabolism. However, it may be falsely positive in inflammatory lesions which may occasionally hinder its ability to differentiate between benign and malignant lesions.

• Apart from prostatic malignancy, PSMA is overexpressed in neovasculature of many non-prostatic malignancies. The present study highlights that Ga68 PSMA PET/CT performed better in diagnosing malignancy non-invasively than FDG-PET/CT with a higher PPV (90.5% vs. 65.4%) and accuracy (92.5% vs. 72.5%).

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Abbreviations

CECT:

Contrast-enhanced computed tomography

EUS:

Endoscopic ultrasonogram

F-18 FDG:

2-deoxy-2-(18F) fluoro-d-glucose

FNAC/B:

Fine needle aspiration cytology/biopsy

FWHM:

Full width at half maximum

Ga-68 PSMA:

68Ga-Glu-NH-CO-NH-Lys(Ahx)-HBED-CC

HBED–CC:

N,N′-bis [2-hydroxy-5-(carboxyethyl)benzyl] ethylenediamine N,N′-diacetic acid

HPE:

Histopathological examination

IHC:

Immunohistochemistry

IPMN:

Intraductal papillary mucinous neoplasm

IQR:

Interquartile range

KeV:

Kiloelectron volt

mA:

Milliampere

MBq:

Megabecquerel

mCi:

Millicurie

MDCT:

Multidetector computed tomography

MRCP:

Magnetic resonance cholangiopancreatography

MRI:

Magnetic resonance imaging

mRNA:

Messenger ribonucleic acid

OSEM:

Ordered subset expectation maximization

PET/CT:

Positron emission tomography/computed tomography

PSMA:

Prostate-specific membrane antigen

ROC:

Receiver operator characteristic curve

ROI:

Region of interest

SUVmax:

Standardized uptake value

SUVmaxFDG :

Standardized uptake value – maximum on 18F-FDG PET/CT

SUVmaxPSMA :

Standardized uptake value – maximum on 68Ga-PSMA PET/CT

TBR:

Target to background ratio

TP/TN/FP/FN:

True positive/true negative/false positive/false negative

USG:

Ultrasonography

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Funding

The authors state that this work has not received any funding.

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Author notes

  1. Venkata Subramanian Krishnaraju and Rajender Kumar both contributed equally as first authors

Authors and Affiliations

  1. Department of Nuclear Medicine and PET/CT, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

    Venkata Subramanian Krishnaraju, Rajender Kumar, Bhagwant Rai Mittal & Harmandeep Singh

  2. Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Vishal Sharma & Surinder S. Rana

  3. Department of Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Harjeet Singh

  4. Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Ritambhra Nada & Amanjit Bal

  5. Department of Cytology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Manish Rohilla

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  1. Venkata Subramanian Krishnaraju
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Correspondence to Bhagwant Rai Mittal.

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The scientific guarantor of this publication is Prof. Bhagwant Rai Mittal.

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Statistics and biometry

Venkata Subramanian Krishnaraju, who is one of the authors, has significant statistical expertise.

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Written informed consent was obtained from all subjects (patients) in this study.

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Krishnaraju, V.S., Kumar, R., Mittal, B.R. et al. Differentiating benign and malignant pancreatic masses: Ga-68 PSMA PET/CT as a new diagnostic avenue. Eur Radiol 31, 2199–2208 (2021). https://doi.org/10.1007/s00330-020-07318-2

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  • DOI: https://doi.org/10.1007/s00330-020-07318-2

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