Although some clinical and radiological features may predict malignancy presence in intraductal papillary mucinous pancreas neoplasms, preoperative diagnosis remains difficult. In this study we present 7 patients with Intraductal Papillary Mucinous Neoplasm (IPMN) studied both with 18FDG-PET and magnetic resonance cholangiopancreatography (MRCP). A focal hypermetabolism was documented in 2 patients (the standardized uptake value in the neoplastic foci was 6.7 and 9), while absence of FDG uptake in the neoplasm area was recorded in the remaining 5 cases. Mean follow-up was 27 months (range 21–34). The final judgement was benign IPMN in 5 cases and malignant IPMN in 2. PET scan always correctly predicted the presence or absence of malignancy, while MRCP failed to detect malignancy in 3/7 cases. In conclusion, this preliminary experience suggests that 18FDG-PET may prove useful for malignancy detection in IPMN, improving differential diagnosis with benign intraductal papillary growth by functional data

C Fernandez-del Castillo

C Sperti

Claudio Pizzocaro

DS Longnecker

F Maire

Federico Gheza

Francesco Bertagna

Gian Luca Baiocchi

JC Mansour

KL Berger

M Falconi

M Sugiyama

M Tanaka

M Yoshioka

Nazario Portolani

P Berberat

R Salvia

Raffaele Giubbini

Stefano M Giulini

English

PubMed

Crossref

BioMed Central
Journal of Experimental & Clinical 
Cancer Research
ssOpen AcceResearch
Possible additional value of 18FDG-PET in managing pancreas 
intraductal papillary mucinous neoplasms: Preliminary results
Gian Luca Baiocchi*1, Nazario Portolani1, Francesco Bertagna2, 
Federico Gheza1, Claudio Pizzocaro2, Raffaele Giubbini2 and 
Stefano M Giulini1
Address: 1Department of Medical and Surgical Sciences, Surgical Clinic, University of Brescia, Brescia, Italy and 2Nuclear Medicine Service, Brescia 
Civil Hospital, Brescia, Italy
Email: Gian Luca Baiocchi* - baioksurg@hotmail.com; Nazario Portolani - portolani@med.unibs.it; Francesco Bertagna - bertagna@libero.it; 
Federico Gheza - federico.gheza@libero.it; Claudio Pizzocaro - pizzocaro@alice.it; Raffaele Giubbini - giubbini@med.unibs.it; 
Stefano M Giulini - giulini@med.unibs.it
* Corresponding author    
Abstract
Although some clinical and radiological features may predict malignancy presence in intraductal
papillary mucinous pancreas neoplasms, preoperative diagnosis remains difficult. In this study we
present 7 patients with Intraductal Papillary Mucinous Neoplasm (IPMN) studied both with 18FDG-
PET and magnetic resonance cholangiopancreatography (MRCP). A focal hypermetabolism was
documented in 2 patients (the standardized uptake value in the neoplastic foci was 6.7 and 9), while
absence of FDG uptake in the neoplasm area was recorded in the remaining 5 cases. Mean follow-
up was 27 months (range 21–34). The final judgement was benign IPMN in 5 cases and malignant
IPMN in 2. PET scan always correctly predicted the presence or absence of malignancy, while
MRCP failed to detect malignancy in 3/7 cases. In conclusion, this preliminary experience suggests
that 18FDG-PET may prove useful for malignancy detection in IPMN, improving differential
diagnosis with benign intraductal papillary growth by functional data.
Background
Cystic pancreas tumours are observed with increasing fre-
quency in asymptomatic patients as incidental findings
during US or CT abdominal imaging. Pancreatic resection,
the only available therapy, may represent an over-treat-
ment due to the low malignant potential of more than
half of these lesions [1]. Within the whole group of cystic
pancreas tumours, preoperative imaging, including mag-
netic resonance cholangiopancreatography (MRCP) and
endoscopic ultrasound, usually allows three main lesions
to be differentiated: serous adenoma, mucinous tumour
and IPMN (intraductal papillary mucinous neoplasm)
[2]. While in the two former tumours the indications are
well recognised (radiological follow-up for serous and
resection for mucinous neoplasms), IPMN still represents
a more critical field, potentially bearing adenoma, in situ
carcinoma or invasive carcinoma; these lesions cannot be
differentiated with sufficient accuracy by currently availa-
ble imaging techniques.
In the search for a diagnostic tool improving malignant
IPMN preoperative detection accuracy, 18FDG-PET was
Published: 10 June 2008
Journal of Experimental & Clinical Cancer Research 2008, 27:10 doi:10.1186/1756-9966-27-
10
Received: 9 May 2008
Accepted: 10 June 2008
This article is available from: http://www.jeccr.com/content/27/1/10
© 2008 Baiocchi et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Journal of Experimental & Clinical Cancer Research 2008, 27:10 http://www.jeccr.com/content/27/1/10poorly investigated in the published series. This paper's
aim is to discuss the potential of this functional imaging
technique in managing IMPN, based on a preliminary
monocentric experience.
Methods
In the period 2003–2005, 28 patients with a conclusive
diagnosis of IPMN were observed in the Surgical Clinic of
Brescia University. The radiological workup included
magnetic resonance cholangiopancreatography (MRCP)
in 26 patients and CT scan in 23 patients. Endoscopic
ultrasonography was performed in 13 patients (in 6 cases
with fine needle aspiration of the cystic contents). MRCP
was conducted with noncontrast, T2-weighted, fat-sup-
pressed, HASTE sequences, T1-weighted, fat-suppressed
WIBE sequences, and dynamic gadolinium administra-
tion; postcontrast MR images were acquired on transverse,
coronal and axial planes. 16-row multidetector CT scan
was performed with water gastric filling and endovenous
contrast medium injection; reconstruction along the
course of the main pancreatic duct was possible using
multiplanar reformatted images and 3-dimensional repre-
sentations.
In 7 cases, 18FDG-PET/CT was performed. All the patients
had fasted for at least 6 hours beforehand, had glucose
levels below 150 mg/dl, and good hydratation. 5.5 MBq/
Kg were injected intravenously. 2D mode OS-EM imaging
(with septa) was acquired 60 minutes after injection on a
Discovery ST PET/CT tomograph (GE®) using CT for atten-
uation correction (characteristics: 80 mA, 120 Kv without
contrast; CT slice thickness of 3.75 mm to approximate
the PET slice width; reconstructed slice interval of 3.27
mm to match the PET slice spacing; 4 minutes per bed-
PET-step of 15 cm). The PET images were analyzed visu-
ally and semi-quantitatively using the standardized
uptake value (SUVbw, g/ml). The reconstruction was per-
formed in a 128 × 128 matrix and 60 cm FOV (field of
view). Transaxial, coronal, and sagittal sections were
obtained for visual analysis, performed according to a col-
our scale. All patients gave written consensus to perform
the exam.
Surgical resection was proposed, according to the Interna-
tional Consensus Guidelines [3], for all main duct type
IPMNs, and for branch duct type IPMNs larger than 3 cm
or symptomatic or with mural nodules at MRCP. The final
diagnosis of benign or malignant IPMN was deduced
from the pathological report in the resected patients and
from the clinical and radiological follow-up in the
observed patients, in accordance with the criteria adopted
in recently published series [4-6].
Results
An intense focal hyper metabolism was documented by
18FDG-PET in 2 patients (SUV in the neoplastic foci was
6.7 and 9 respectively); 18FDG-PET images showed com-
plete absence of FDG uptake in the neoplasm area in the
remaining 5 cases (Table 1). In the 2 PET positive cases,
MRCP also presented morphological aspects indicative of
potential malignancy, as the main duct was involved in
both and a nodal metastasis was suspected in one. The
first patient, an 83 year-old man with severe chronic respi-
ratory distress, was not operated owing to high surgical
risk; percutaneous jaundice palliation was performed, and
the patient died from the tumour 5 months later. The sec-
ond patient was a 67 year-old female submitted to total
pancreasectomy; histological examination demonstrated
in situ carcinoma, located in the cephalic region where the
PET scan showed a focal hyperintensity signal (Fig. 1).
Out of the 5 PET negative patients, 3 were MRCP positive
for potential malignancy, because of main duct involve-
ment (1 case) and mural nodules located inside a branch
duct type cyst larger than 3 cm (2 cases), one of which
increasing in size in serial examinations. Two of these PET
negative/MRCP positive patients were resected with defin-
itive histological diagnosis of benign IPMN, while the
third patient, an 81 year-old woman candidate to pancre-
atico-duodenectomy, was excluded from surgery owing to
the high surgical risk and is alive and with an unmodified
cyst at the 26 month control. The remaining two patients
were both PET and MRCP negative for malignancy; they
were observed, and their lesions were found to be stable
in size and structure by MRCP controls, respectively after
21 and 34 months follow-up.
PET scan of patient N. 2, showing a focal hyperintensity signal at pancreatic head level; t e magnetic resonance cholagio-pancre tography (MRCP) showed the presence of a c stic dilatatio  of t  whol  Wirsung uctFigu e 1
PET scan of patient N. 2, showing a focal hyperinten-
sity signal at pancreatic head level; the magnetic reso-
nance cholagiopancreatography (MRCP) showed the 
presence of a cystic dilatation of the whole Wirsung duct. 
Total pancreasectomy was performed, with a final diagnosis 
of in situ carcinoma within the cephalic Wirsung duct.Page 2 of 4
(page number not for citation purposes)
Journal of Experimental & Clinical Cancer Research 2008, 27:10 http://www.jeccr.com/content/27/1/10On the basis of the final evaluation obtained by histopa-
thology or follow-up, in the 7 cases studied by MRCP and
PET scan, MRCP gave 3 false out of 5 responses positive
for malignancy with no false negatives, while the PET
diagnosis was always correct in confirming or excluding
malignancy.
Discussion
The IPMN therapeutic strategy mainly depends on the sus-
picion of malignancy emerging from the preoperative
workup. Although some radiological features have been
described that may indicate a definite risk – all main duct
tumours and branch duct tumours larger than 3 cm,
symptomatic or harbouring parietal nodules [3] – no clin-
ical, biological, biochemical and radiological factors can
be considered sufficiently accurate to confirm or exclude
malignant component presence in cyst walls [7-10], fre-
quently leading to an aggressive approach to lesions
which finally prove to be absolutely benign. Considering
that pancreatic resection is a very invasive operation, with
mortality of 5–10% and morbidity of 20–40%, and that
in most IPMNs the only therapeutic procedure able to
remove the disease entirely is total pancreasectomy, a
diagnostic tool improving malignancy diagnosis specifi-
city may represent substantial progress in managing these
lesions. The accuracy of CT scan is very low in this field,
while MRCP is the gold standard diagnostic procedure,
due to its ability to demonstrate the Wirsung duct anat-
omy and its connections to branch-sided cysts, and to
exclude the presence of parietal nodules or filling defects.
In the present series, considering the entire cohort of
patients, MRCP proved to be better than CT both for a cor-
rect diagnosis of the pancreatic cystic neoplasm as IPMN
(100% versus 73.9%) and for the recognition of patients
at high risk of malignancy (sensibility, specificity, positive
and negative predictive value were respectively 100%,
75%, 54.4% and 100% for MRCP and 40% 88.8%, 50%
and 84.2% for CT).
Positron emission tomography (18FDG-PET) is a func-
tional imaging technique that has been proposed as a val-
uable tool for diagnosing and staging different
malignancies, including pancreatic adenocarcinoma [11].
Some published experiences have reported low 18FDG-
PET sensitivity in detecting malignant tissue presence in
cystic lesions: 57% in the Mansour study including 68
patients with pancreatic cystic tumours [4], and 59% in 22
patients with mucinous carcinoma from a variety of
organs, including 2 pancreatic tumours, presented by
Berger and Coll. [5]; these figures were considered as inad-
equate by the Authors, concluding that no therapeutic
decision could be based on PET scan. On the contrary,
Sperti and Coll. reported a series of 56 cystic pancreas neo-
plasms, in which 18FDG-PET sensitivity, specificity, posi-
tive and negative predictive values were respectively 94%,
97%, 94%, and 97% [6]. From the cited papers, including
all the different types of pancreatic cystic tumours, it is
impossible to enucleate the data concerning the IPMN
subgroup. Five and 17 IPMNs were respectively present in
the Memorial Sloan Kettering Cancer Centre study [4] and
from Italy [6]. In these papers, three cases of IPMNs with
in situ carcinoma and one case of invasive papillary carci-
noma were correctly marked positive at PET scan, but one
IPMN case with in situ carcinoma without metabolic
activity at PET was described by Mansour, while no false
negative PET scans were reported by Sperti. To the best of
our knowledge no further paper specifically focused on
this topic has been published, apart from a report of 2
cases of IPMNs studied by PET described by Yoshioka in
2003 [12].
In our patients the 18FDG-PET results always agreed with
the final malignancy: in the 4 patients with definitive
diagnosis (3 histological examination and 1 disease-
related death), PET added specificity to MRCP, correctly
excluding malignancy in the 2 benign cases, which pre-
sented aspects considered indicative of malignancy at
Table 1: Data summary of 7 patients with IPMN undergoing magnetic resonance cholagiopancreatography (MRCP) and 18FDG-PET 
scan in the preoperative workup.
Pt Data indicative of malignancy Therapy Final diagnosis
MRCP PET
1 POSITIVE POSITIVE Follow-up* Malignant
2 POSITIVE POSITIVE Total pancreatectomy Malignant
3 POSITIVE NEGATIVE Distal pancreatectomy Benign
4 POSITIVE NEGATIVE Distal pancreatectomy Benign
5 POSITIVE NEGATIVE Follow-up** (26 months) Benign
6 NEGATIVE NEGATIVE Follow-up (21 months) Benign
7 NEGATIVE NEGATIVE Follow-up (34 months) Benign
* not operated for high surgical risk, dead for disease after 5 months
** not operated for high surgical riskPage 3 of 4
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MRCP, and demonstrated good sensitivity, showing high
FDG uptake areas in the two malignant lesions. The
remaining 3 cases not submitted to resection, classified as
benign on the basis of the uneventful follow-up in accord-
ance with the criteria adopted by the previously cited stud-
ies [4-6], were correctly defined negative at PET,
confirming PET accuracy in excluding malignancy. PET
scan was therefore always accurate in the 7 cases of this
series, correctly defining the nature of the 5 benign
lesions, as well as of the 2 malignant ones. The PET posi-
tivity of an situ carcinoma in 1 patient is particularly inter-
esting, confirming the 3 similar cases previously described
[4,6], and means that even a small amount of tissue with
increased metabolic activity, in an initial phase of the can-
cerization process, may be detected. By analysing meta-
bolic activity within the wall of a cystic lesion, PET scan
offers the possibility of investigating the nature of small
mural nodules, morphologically demonstrated by MRCP
by functional data, so discriminating benign and malig-
nant lesions.
Conclusion
PET scan, combined with MRCP, may thus add specificity
to a preoperative study based on MRCP alone, preventing
unnecessary pancreatic resections. Its value in managing
IPMN merits further investigation.
Authors' contributions
GB conceived of the study and drafted the manuscript, FB,
CP and RG performed the nuclear medicine examina-
tions, FG, NP and SMG participated in the design of the
study. All authors read and approved the final manuscript.
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Possible additional value of 18FDG-PET in managing pancreas intraductal papillary mucinous neoplasms: Preliminary results

PORTOLANI, Nazario

BERTAGNA, Francesco

GHEZA, Federico

PIZZOCARO, Claudio

GIUBBINI, Raffaele

GIULINI, Stefano Maria

Archivio istituzionale della ricerca - Università di Brescia

Abstract Although some clinical and radiological features may predict malignancy presence in intraductal papillary mucinous pancreas neoplasms, preoperative diagnosis remains difficult. In this study we present 7 patients with Intraductal Papillary Mucinous Neoplasm (IPMN) studied both with 18FDG-PET and magnetic resonance cholangiopancreatography (MRCP). A focal hypermetabolism was documented in 2 patients (the standardized uptake value in the neoplastic foci was 6.7 and 9), while absence of FDG uptake in the neoplasm area was recorded in the remaining 5 cases. Mean follow-up was 27 months (range 21–34). The final judgement was benign IPMN in 5 cases and malignant IPMN in 2. PET scan always correctly predicted the presence or absence of malignancy, while MRCP failed to detect malignancy in 3/7 cases. In conclusion, this preliminary experience suggests that 18FDG-PET may prove useful for malignancy detection in IPMN, improving differential diagnosis with benign intraductal papillary growth by functional data.</p

Pizzocaro Claudio

Gheza Federico

Bertagna Francesco

Portolani Nazario

Baiocchi Gian

Giubbini Raffaele

Giulini Stefano M

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Gian Baiocchi

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Atomi Y: Intraductal papillary mucinous tumors of the pancreas: imaging studies and treatment strategies. Ann Surg

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Main-duct intraductal papillary mucinous neoplasms of the pancreas: clinical predictors of malignancy and long-term survival following resection. Ann Surg

MW: Diagnosis and staging of pancreatic cancer by positron emission tomography. World J Surg

Pedrazzoli S: F-18-fluorodeoxyglucose positron emission tomography in differentiating malignant from benign pancreatic cysts: a prospective study.

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Possible additional value of 18FDG-PET in managing pancreas intraductal papillary mucinous neoplasms: Preliminary results

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