Carotid plaque inflammation and calcification on somatostatin receptor PET/CT imaging predict stroke and major adverse cardiovascular events

PURPOSE: Carotid atherosclerosis is a risk factor for stroke and major adverse cardiovascular events (MACE) and is characterized by inflammation and calcification at different stages. Simultaneous assessment of both features may improve risk stratification. We therefore evaluated whether combined assessment of carotid plaque inflammation and calcification on [⁶⁸Ga]DOTA-TOC PET/CT predicts stroke and MACE in a real-world oncologic population. METHODS: We retrospectively included patients who underwent [⁶⁸Ga]DOTA-TOC PET/CT for suspected or confirmed neuroendocrine tumors. Carotid plaques were assessed visually and semiquantitatively on PET/CT, and patients were categorized into four groups according to the patient-level presence of carotid artery calcification and/or focal [⁶⁸Ga]DOTA-TOC uptake. Median follow-up was 55 months (IQR 42-72). Stroke and MACE, defined as myocardial infarction, hospitalization for myocardial ischemia, coronary revascularization, and cardiac death, were recorded. RESULTS: A total of 353 patients were evaluated. Carotid artery calcification was present in 123/353 (34.8%) patients, with a median calcification volume of 77.7 cm³ (IQR 27.9-169.8). Forty-six patients (13.0%) showed 67 foci of [⁶⁸Ga]DOTA-TOC uptake, with median SUVmax 1.68 (IQR 1.55-1.93) and median TBR 2.14 (IQR 1.65-2.79). Patients with both calcified and inflamed carotid plaques had the highest rates of stroke (15.2%) and MACE (12.1%) versus all other groups (P<0.05). In multivariable Cox analysis, this combined patient-level phenotype remained independently associated with stroke and MACE and remained significant in competing-risk analyses. CONCLUSIONS: [⁶⁸Ga]DOTA-TOC PET/CT enables simultaneous assessment of macrophage-related carotid plaque inflammation and calcification and identifies a subgroup at particularly high risk of stroke and MACE.