Complementary roles of 68Ga-FAPI and 18 F-FDG PET/CT in evaluating IgG4-related disease: a systematic review and pooled analysis

IgG4-related disease (IgG4-RD) lacks standardized imaging criteria. This study systematically reviewed head-to-head comparisons of ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT to clarify their complementary roles in diagnosing and staging IgG4-RD.

Three high-quality studies (n = 90) were pooled. ⁶⁸Ga-FAPI showed significantly higher SUVmax and target-to-background ratios (TBR) in parenchymal organs (pancreas, salivary glands) vs. ¹⁸F-FDG (P < 0.001), offering superior lesion contrast. While ¹⁸F-FDG detected more lymph node activity, ⁶⁸Ga-FAPI identified 136 vs. 78 total lesions, improving systemic burden assessment. Pathology correlated FAPI with fibrosis and FDG with inflammation, defining a “flip-flop” pattern. A FAPI/FDG ratio ≥ 1.5 predicted relapse risk.

⁶⁸Ga-FAPI excels in parenchymal organ involvement, while FDG highlights inflammatory lymphadenopathy. Combining both tracers enables multimodal evaluation of fibroinflammatory activity, guiding personalized management and prognostication in IgG4-RD.