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Al Zahra Hospital, Dubai, UAE

Evaluating the diagnostic superiority of Ga-FAPI PET/CT in malignant tumorsAl Zahra Hospital, Dubai, UAE
Courtesy of Dr. Pedro Quaresma, European Board-Certified Nuclear Medicine Consultant



Introduction

The advent of Ga-68 FAPI PET imaging marks a paradigm shift in molecular oncology, offering unprecedented precision in visualizing fibroblast activation protein expression across a spectrum of malignancies. By combining high tumor-to-background contrast with rapid pharmacokinetics, Ga-68 FAPI redefines diagnostic accuracy and opens new frontiers for theranostic applications in cancer care.68Gallium-labeled Fibroblast Activation Protein Inhibitor (68Ga =FAPI is a novel PET tracer that binds specifically to fibroblast activation protein (FAP), which is overexpressed in cancer-associated fibroblasts and activated myofibroblasts. Beyond its growing role in oncology with superior tumor-to-background contrast, recent research suggests significant utility in cardiovascular disease imaging, including myocardial infarction, cardiomyopathies, amyloidosis, and post-therapy cardiotoxicity. Future research should establish standardized uptake metrics, optimal imaging timing, and prognostic insights Its ability to deliver high tumor-to-background contrast and rapid clearance positions FAPI technology as a transformative tool in oncology, paving the way for more accurate diagnosis, staging, and potential theranostic applications. Currently, 68Ga-FAPI is under approvals by the U.S. Food and Drug Administration (FDA) through approved Investigational New Drug (IND) applications, enabling Phase 2 and Phase 3 clinical trials in oncology indications such as gastrointestinal and pancreatic cancers. Its application is mainly in restaging diagnosis, staging, and in a wide range of solid tumors: breast, lung, gastrointestinal, head and neck, pancreatic, cholangiocarcinoma, sarcoma. FAPI PET often shows improved lesion detection sensitivity over FDG and also in potential roles like theranostics via FAP-targeted therapies and radionuclide delivery (research context) monitoring treatment responses and assessing tumor microenvironment changes over time.

Fig 1A & 1B: Demonstrate axial & coronal view of the PET-CT which showcases hypermetabolic activity in hepatic segments IV/V.
Fig 1A & 1B: Demonstrate axial & coronal view of the PET-CT which showcases hypermetabolic activity in hepatic segments IV/V.

Clinical Case Study 

Advanced Gallbladder Adenocarcinoma with Osseous Metastasis Evaluated by FAPI PET-CT Patient Profile:

Patient Profile

A 31-year-old male presented with a diagnosis of poorly differentiated biliary-type adenocarcinoma of the gallbladder (Grade 3), initially identified following laparoscopic cholecystectomy. Histopathology revealed a 3 cm tumor invading the liver (pT3), with positive hepatic resection margin (R1), lymphovascular and perineural invasion, and involvement of one cystic duct lymph node (pN1).

Initial Staging and Imaging

The patient underwent FAPI PET-CT on the advance PET-CT platform with FlowMotion technology which enables continuous bed movement during PET acquisition, replacing the conventional step-and-shoot approach. This method allows tailored scanning speeds for different anatomical regions, improving image quality and reducing radiation exposure. This process minimizes motion artifacts & therefore consistent quantitative accuracy across the entire scan. Due to demonstrated hypermetabolic activity in hepatic segments IV/V and a suspicious focus in the right transverse process of T8. MRI of the thoracic spine confirmed metastatic involvement at T8.

Nuclear Medicine Technology Team
Nuclear Medicine Technology Team

Teaching Point

Ga-68 FAPI PET imaging stands out as a transformative tracer in oncology due to its ability to target fibroblast activation protein (FAP), which is highly expressed in cancer-associated fibroblasts within the tumor microenvironment. Unlike conventional tracers such as FDG, Ga-68 FAPI offers exceptionally high tumor-to-background contrast, minimal physiological uptake in most normal tissues, and rapid clearance, enabling clearer visualization of lesions even in challenging regions like the abdomen and pelvis. Its unique mechanism provides superior sensitivity for detecting primary tumors, metastases, and stromal involvement, while reducing false positives linked to inflammation or glucose metabolism. These advantages position Ga-68 FAPI as a next-generation imaging agent with broad applicability and potential theranostic benefits in precision.

"Ga-68 FAPI PET imaging stands out as a transformative tracer in oncology due to its ability to target fibroblast activation protein (FAP), which is highly expressed in cancer-associated fibroblasts within the tumor microenvironment."
Dr. Pedro Quaresma
Dr. Pedro Quaresma
European Board-Certified Nuclear 
Medicine Consultant 
Al Zahra Hospital, Dubai, UAE