Abstract / Summary
Abstract Purpose To evaluate the diagnostic contribution of 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/computed tomography ([¹⁸F]FDG PET/CT) metabolic, volumetric, and morphological parameters in differentiating human immunodeficiency virus (HIV)-related reactive lymphadenopathy (LAP), lymphoma, and tuberculosis (TB) in people living with HIV. Methods PET/CT images of 96 patients with HIV (2010–2025) with reactive LAP (n = 67), lymphoma (n = 16), or TB (n = 13) were retrospectively reviewed. Maximum standardized uptake value (SUVmax), SUVmax-to-liver ratio (SURmax), metabolic tumor volume (MTV), total lesion glycolysis (TLG), nodal morphology, extranodal involvement, and maximum-intensity-projection (MIP) symmetry were compared among groups, and the association of antiretroviral therapy (ART) exposure with PET/CT parameters was assessed within the reactive LAP group. Results SUVmax and SURmax were significantly lower in reactive LAP than in lymphoma and TB (p < 0.001), with cut-offs of 16.46 (area under the curve [AUC] 0.959) and 3.83 (AUC 0.934) showing high discriminatory performance in distinguishing reactive LAP from lymphoma. MTV and TLG were higher in lymphoma and TB (p < 0.001). Symmetric MIP uptake was present in 98.5% of reactive LAP versus 56.2% of lymphoma and 46.2% of TB cases and was strongly associated with reactive LAP (p < 0.001). SUVmax, SURmax, MTV, and TLG were significantly lower in ART-experienced than ART-naïve reactive LAP patients (p < 0.001), and [¹⁸F]FDG PET/CT guided biopsy target selection in 87.8% of biopsied patients. Conclusion [¹⁸F]FDG PET/CT may aid differentiation of reactive lymphadenopathy from lymphoma and tuberculosis in people living with HIV through combined metabolic, volumetric, and morphological parameters — particularly MIP symmetry — and effectively guides biopsy planning. However, substantial overlap remains between lymphoma and tuberculosis.