Real-world evidence in a large cohort comparing FAPI and FDG PET/CT for hepatopancreatobiliary cancer diagnosis
7 affiliations
- 1Department of Nuclear Medicine, Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India
- 2Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
- 3Rotterdam, 3015 GD The Netherlands
- 4Department of Gastroenterology and Hepatology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
- 5Department of Gastroenterology, Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India
- 6Department of Artificial Intelligence, Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India
- 7Department of Epidemiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
Abstract
Purpose: Diagnosing hepatopancreatobiliary (HPB) malignancies remains challenging. Conventional imaging often lacks sensitivity for occult nodal and distant metastases, and FDG PET/CT has variable performance due to low uptake in several tumour subtypes and false-positive uptake in inflammation. Fibroblast activation protein inhibitor (FAPI) PET/CT has emerged as a promising alternative. This study compared the diagnostic accuracy of FDG PET/CT, FAPI PET/CT, and a dual-tracer approach in suspected HPB malignancies.
Methods: This retrospective analysis included patients who underwent both [18F]FDG and [68Ga]Ga-FAPI-46 PET/CT for suspected HPB cancer, including cholangiocarcinoma, gallbladder carcinoma, pancreatic carcinoma, periampullary carcinoma, and hepatocellular carcinoma. Histopathology and/or clinical follow-up served as reference standard. FDG PET/CT classification used an SUVmax cut-off derived from receiver-operating characteristic analysis, while FAPI PET/CT classification followed expert clinical interpretation. Sensitivity, specificity, and accuracy metrics were compared using paired statistics.
Results: 176 patients were included. FAPI PET/CT demonstrated higher sensitivity than FDG PET/CT (93.0% vs. 76.5%, p = 0.002). Primary tumour diagnostic accuracy was 78.9% for FAPI versus 68.3% for FDG (p = 0.021). A dual-tracer approach did not outperform FAPI (76.7% vs. 78.9%, p = 0.711). For nodal disease, FAPI showed 86.8% diagnostic accuracy, compared with 71.1% for FDG (p = 0.004), driven by higher specificity. For distant metastases, accuracy was 83.9% for FAPI versus 80.0% for FDG (p = 0.625).
Conclusion: FAPI PET/CT outperformed FDG PET/CT in this retrospective analysis, with dual-tracer imaging offering no additional benefits. These results show great promise for clinical application of FAPI PET/CT for the detection of HPB tumours and their metastases to be confirmed by independent prospective studies.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00259-026-08112-w.
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BibTeX
@article{batchu2026realworld,
title = {{Real-world evidence in a large cohort comparing FAPI and FDG PET/CT for hepatopancreatobiliary cancer diagnosis}},
author = {Suneetha Batchu and Mara M.K. Veenstra and David M. de Jong and Mohan Roop Jayanthi and Erik Vegt and Sana F. Memon and Abhishek Tyagi and Daniel Bos and Sundeep Lakhtakia and Marco J. Bruno and D. Nageshwar Reddy and Hardik Rughwani and Maarten G.J. Thomeer},
journal = {European Journal of Nuclear Medicine and Molecular Imaging},
year = {2026},
month = aug,
doi = {10.1007/s00259-026-08112-w},
url = {https://doi.org/10.1007/s00259-026-08112-w},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Real-world evidence in a large cohort comparing FAPI and FDG PET/CT for hepatopancreatobiliary cancer diagnosis
AU - Suneetha Batchu
AU - Mara M.K. Veenstra
AU - David M. de Jong
AU - Mohan Roop Jayanthi
AU - Erik Vegt
AU - Sana F. Memon
AU - Abhishek Tyagi
AU - Daniel Bos
AU - Sundeep Lakhtakia
AU - Marco J. Bruno
AU - D. Nageshwar Reddy
AU - Hardik Rughwani
AU - Maarten G.J. Thomeer
PY - 2026
DA - 2026/08/12
JO - European Journal of Nuclear Medicine and Molecular Imaging
DO - 10.1007/s00259-026-08112-w
UR - https://doi.org/10.1007/s00259-026-08112-w
AB - Purpose: Diagnosing hepatopancreatobiliary (HPB) malignancies remains challenging. Conventional imaging often lacks sensitivity for occult nodal and distant metastases, and FDG PET/CT has variable performance due to low uptake in several tumour subtypes and false-positive uptake in inflammation. Fibroblast activation protein inhibitor (FAPI) PET/CT has emerged as a promising alternative. This study compared the diagnostic accuracy of FDG PET/CT, FAPI PET/CT, and a dual-tracer approach in suspected HPB malignancies. Methods: This retrospective analysis included patients who underwent both [18F]FDG and [68Ga]Ga-FAPI-46 PET/CT for suspected HPB cancer, including cholangiocarcinoma, gallbladder carcinoma, pancreatic carcinoma, periampullary carcinoma, and hepatocellular carcinoma. Histopathology and/or clinical follow-up served as reference standard. FDG PET/CT classification used an SUVmax cut-off derived from receiver-operating characteristic analysis, while FAPI PET/CT classification followed expert clinical interpretation. Sensitivity, specificity, and accuracy metrics were compared using paired statistics. Results: 176 patients were included. FAPI PET/CT demonstrated higher sensitivity than FDG PET/CT (93.0% vs. 76.5%, p = 0.002). Primary tumour diagnostic accuracy was 78.9% for FAPI versus 68.3% for FDG (p = 0.021). A dual-tracer approach did not outperform FAPI (76.7% vs. 78.9%, p = 0.711). For nodal disease, FAPI showed 86.8% diagnostic accuracy, compared with 71.1% for FDG (p = 0.004), driven by higher specificity. For distant metastases, accuracy was 83.9% for FAPI versus 80.0% for FDG (p = 0.625). Conclusion: FAPI PET/CT outperformed FDG PET/CT in this retrospective analysis, with dual-tracer imaging offering no additional benefits. These results show great promise for clinical application of FAPI PET/CT for the detection of HPB tumours and their metastases to be confirmed by independent prospective studies. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00259-026-08112-w.
SN - 1619-7070
SN - 1619-7089
ER -