Background: Patients with non-small cell lung cancer (NSCLC) driven by activating epidermal growth factor receptor (EGFR) mutations are best treated with therapies targeting EGFR, i.e., tyrosine kinase inhibitors (TKI). Radiolabeled EGFR-TKI and PET have been investigated to study EGFR-TKI kinetics and its potential role as biomarker of response in NSCLC patients with EGFR mutations (EGFRm). In this study we aimed to compare the biodistribution and kinetics of three different EGFR-TKI, i.e., ¹¹C-erlotinib, ¹⁸F-afatinib and ¹¹C-osimertinib.

Methods: Data of three prospective studies and 1 ongoing study were re-analysed; data from thirteen patients (EGFRm) were included for ¹¹C-erlotinib, seven patients for ¹⁸F-afatinib (EGFRm and EGFR wild type) and four patients for ¹¹C-osimertinib (EGFRm). From dynamic and static scans, SUV and tumor-to-blood (TBR) values were derived for tumor, lung, spleen, liver, vertebra and, if possible, brain tissue. AUC values were calculated using dynamic time-activity-curves. Parent fraction, plasma-to-blood ratio and SUV values were derived from arterial blood data. Tumor-to-lung contrast was calculated, as well as (background) noise to assess image quality.

Results: ¹¹C-osimertinib showed the highest SUV and TBR (AUC) values in nearly all tissues. Spleen uptake was notably high for ¹¹C-osimertinib and to a lesser extent for ¹⁸F-afatinib. For EGFRm, ¹¹C-erlotinib and ¹⁸F-afatinib demonstrated the highest tumor-to-lung contrast, compared to an inverse contrast observed for ¹¹C-osimertinib. Tumor-to-lung contrast and spleen uptake of the three TKI ranked accordingly to the expected lysosomal sequestration.

Conclusion: Comparison of biodistribution and tracer kinetics showed that ¹¹C-erlotinib and ¹⁸F-afatinib demonstrated the highest tumor-to-background contrast in EGFRm positive tumors. Image quality, based on contrast and noise analysis, was superior for ¹¹C-erlotinib and ¹⁸F-afatinib (EGFRm) scans compared to ¹¹C-osimertinib and ¹⁸F-afatinib (EGFR wild type) scans.