Annals of nuclear medicine · 2026
Head-to-head comparison of ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT in intracranial space-occupying lesions.
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Amalo Raydel BrianKwee, Cahyani Aih, Budiawan Hendra, Darmawan Budi, Kusumahstuti Kharisma Perdani, Achmad Arifudin, Hidayat Basuki, Kartamihardja Achmad Hussein Sundawa
Аннотация
PURPOSE: Intracranial space-occupying lesions (SOL), including primary brain tumors, metastases, and inflammatory lesions, require accurate characterization for diagnosis and management. Although ¹⁸F-FDG PET/CT reflects tumor glucose metabolism, its performance in the brain is limited by high physiological uptake. ⁶⁸Ga-FAPI PET/CT targets fibroblast activation protein in the tumor microenvironment and may provide complementary biological information with improved lesion conspicuity. This study aimed to compare ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT for the evaluation of intracranial SOL.
METHODS: Thirty-five patients with 55 intracranial lesions underwent paired ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT within a 7-day interval. Imaging findings were compared with histopathology (n = 9) and/or MRI (n = 46) as reference standards. Lesion detection rate, diagnostic performance, tumor-to-background ratio (TBR), and semi-quantitative uptake parameters normalized to lean body mass (SUL) were evaluated. Receiver operating characteristic (ROC) analyses were performed to assess the ability of each tracer to differentiate neoplastic from non-neoplastic lesions.
RESULTS: ⁶⁸Ga-FAPI PET/CT detected more lesions than ¹⁸F-FDG PET/CT (48/55, 87.3% vs. 36/55, 65.5%) and approached the detection rate of MRI (54/55, 98.2%). FAPI demonstrated higher sensitivity and accuracy, whereas FDG showed higher specificity. FAPI demonstrated a significantly higher tumor-to-background ratio (TBR) than FDG (median, 342.00 [IQR, 164.25-502.00] vs. 4.71 [IQR, 3.48-7.42]; Z = 5.07, p < 0.001) in paired analysis of 34 lesions with measurable uptake on both tracers. In primary tumors, FAPI detected all lesions (13/13), whereas FDG detected 9/13 lesions. ROC analysis showed comparable diagnostic performance for differentiating neoplastic from non-neoplastic lesions (AUC 0.794 for FAPI vs. 0.796 for FDG). Exploratory analysis in high-grade tumors (n = 5) suggested a potential association between higher FDG uptake and shorter overall survival.
CONCLUSION: In this cohort, intracranial lesions were predominantly metastatic, with MRI showing the highest detection rate. Compared with ¹⁸F-FDG PET/CT, ⁶⁸Ga-FAPI PET/CT demonstrated higher lesion detection and tumor-to-background contrast, approaching MRI performance. These findings support a complementary role for ⁶⁸Ga-FAPI PET/CT alongside MRI and ¹⁸F-FDG PET/CT in selected intracranial lesions, particularly when lesion conspicuity is limited by the high physiological brain uptake of FDG.
METHODS: Thirty-five patients with 55 intracranial lesions underwent paired ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT within a 7-day interval. Imaging findings were compared with histopathology (n = 9) and/or MRI (n = 46) as reference standards. Lesion detection rate, diagnostic performance, tumor-to-background ratio (TBR), and semi-quantitative uptake parameters normalized to lean body mass (SUL) were evaluated. Receiver operating characteristic (ROC) analyses were performed to assess the ability of each tracer to differentiate neoplastic from non-neoplastic lesions.
RESULTS: ⁶⁸Ga-FAPI PET/CT detected more lesions than ¹⁸F-FDG PET/CT (48/55, 87.3% vs. 36/55, 65.5%) and approached the detection rate of MRI (54/55, 98.2%). FAPI demonstrated higher sensitivity and accuracy, whereas FDG showed higher specificity. FAPI demonstrated a significantly higher tumor-to-background ratio (TBR) than FDG (median, 342.00 [IQR, 164.25-502.00] vs. 4.71 [IQR, 3.48-7.42]; Z = 5.07, p < 0.001) in paired analysis of 34 lesions with measurable uptake on both tracers. In primary tumors, FAPI detected all lesions (13/13), whereas FDG detected 9/13 lesions. ROC analysis showed comparable diagnostic performance for differentiating neoplastic from non-neoplastic lesions (AUC 0.794 for FAPI vs. 0.796 for FDG). Exploratory analysis in high-grade tumors (n = 5) suggested a potential association between higher FDG uptake and shorter overall survival.
CONCLUSION: In this cohort, intracranial lesions were predominantly metastatic, with MRI showing the highest detection rate. Compared with ¹⁸F-FDG PET/CT, ⁶⁸Ga-FAPI PET/CT demonstrated higher lesion detection and tumor-to-background contrast, approaching MRI performance. These findings support a complementary role for ⁶⁸Ga-FAPI PET/CT alongside MRI and ¹⁸F-FDG PET/CT in selected intracranial lesions, particularly when lesion conspicuity is limited by the high physiological brain uptake of FDG.