Characteristics of 18F-FAPI-04 PET/CT in patients with peritoneal metastasis and to predict treatment efficacy, a head-to-head comparison with 18F-FDG PET/CT

Background F-18-FAPI-04 PET/CT shows promise in detecting peritoneal metastases (PM), but its superiority over F-18-FDG PET/CT for lesion detection and predicting chemotherapy benefit remains unclear. Purpose To compare F-18-FAPI-04 and F-18-FDG PET/CT imaging features in PM and assess predictive value of F-18-FAPI-04 for chemotherapy efficacy. Methods 39 pathologically confirmed PM patients with digestive malignancies underwent concurrent F-18-FAPI-04 and F-18-FDG PET/CT. Semi-quantitative parameters, including SUVmax, tumor/liver ratio (T/L), tumor/mediastinal blood pool ratio (T/B), were analyzed. The tracer uptake was compared via Wilcoxon tests. The relationships between F-18-FAPI-04 uptake with FAP and alpha-SMA expression were analyzed using Pearson correlation. Patients were divided into different short-term outcome groups (responders vs. non-responders) according to RECIST criteria (v.1.1) after chemotherapy. Post-chemotherapy outcomes were evaluated using logistic regression. Results Patients (median age 62; 16 females, 23 males) included pancreatic (n = 17), cholangiocarcinoma (n = 8), gastric (n = 6), and colorectal cancers (n = 8). F-18-FAPI-04 demonstrated significantly higher SUVmax, T/L, and T/B than F-18-FDG (P < 0.05). Pancreaticobiliary cancers (pancreatic/cholangiocarcinoma) exhibited higher 18F-FAPI-04 uptake than gastroenteric cancers (gastric/colorectal) (P < 0.05), though no differences existed within subgroups. F-18-FAPI-04 parameters positively correlated with FAP and alpha-SMA expression. In univariate analysis, F-18-FAPI-04 uptake differed significantly between responders and non-responders. Multivariate analysis identified SUVmax as an independent predictor (OR = 1.354, 95%CI:1.025-1.788, P = 0.033). Optimal F-18-FAPI-04 cut-offs for distinguishing outcomes were SUVmax=11.05 (AUC = 0.783; sensitivity = 70.60%, specificity = 80.40%), T/L = 7.53 (AUC = 0.717; 58.82%, 81.82%), and T/B = 8.76 (AUC = 0.751; 64.71%, 86.37%). Conclusion F-18-FAPI-04 PET/CT outperforms F-18-FDG in PM detection, with semi-quantitative parameters predicting chemotherapy response.