Positron emission tomography and computed tomography with [ 68 Ga]Ga-fibroblast activation protein inhibitors improves tumor detection and staging in patients with pancreatic cancer

Purpose This study aimed to investigate the diagnostic performance of [ 68 Ga]Ga-FAPI PET/CT for primary and metastatic pancreatic carcinoma lesions and compare the results with those of [ 18 F]-fluorodeoxyglucose ([ 18 F]FDG) PET/CT. Methods Patients with suspected or diagnosed pancreatic malignancy, who underwent contemporaneous [ 18 F]FDG and [ 68 Ga]Ga-FAPI PET/CT between June 2020 and January 2021, were retrospectively analyzed. Routine contrast-enhanced CT (CE-CT) is performed in all patients as standardized care. Findings were confirmed by histopathology or radiographic follow-up. We compared radiotracer uptake, diagnostic performance, and TNM (tumor-node-metastasis) classifications. Results We evaluated 36 participants (25/36 men; median age, 60 years), including 26 patients with pancreatic malignancies and ten patients with pancreatic benign lesions. [ 68 Ga]Ga-FAPI PET/CT showed higher radiotracer uptake and higher sensitivity than [ 18 F]FDG PET/CT in evaluating primary tumors (SUVmax, 21.4 vs. 4.8; sensitivity, 100% vs. 73.1%), involved lymph nodes (SUVmax, 8.6 vs. 2.7; sensitivity, 81.8% vs. 59.1%), and metastases (SUVmax, 7.9 vs. 3.5; sensitivity, 91.5% vs. 44.0%); Compared with [ 18 F]FDG, [ 68 Ga]Ga-FAPI PET/CT upstaged six patients’ TNM staging (6/23, 26.1%) and changed two patients’ clinical management (2/23, 8.7%). Compared with CE-CT, [ 68 Ga]Ga-FAPI PET/CT upgraded TNM staging in five patients (5/23, 21.7%) and changed the therapeutic regimen in only one patient (1/23, 4.3%). Intense [ 68 Ga]Ga-FAPI uptake was observed throughout the pancreas in 12/26 pancreatic malignancies; dual-time point [ 68 Ga]Ga-FAPI PET/CT may differentiate pancreatitis from malignancy. Conclusions Compared with [ 18 F]FDG PET/CT, [ 68 Ga]Ga-FAPI PET/CT shows higher sensitivity in detecting primary pancreatic tumors, involved lymph nodes, and metastases and is superior in terms of TNM staging. Prospective trials with larger patient population are needed to evaluate whether [ 68 Ga]Ga-FAPI PET/CT could elicit treatment modification in pancreatic cancer when compared with standard of care imaging.