{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,17]],"date-time":"2026-06-17T17:12:37Z","timestamp":1781716357533,"version":"3.54.5"},"reference-count":48,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2025,1,19]],"date-time":"2025-01-19T00:00:00Z","timestamp":1737244800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background\/Objectives: Over the past four years, 68Ga-fibroblast activation protein inhibitor (FAPI) positron emission tomography\/computed tomography (PET\/CT) has been established at a tertiary cancer care facility in Jordan. This retrospective study aims to explore tracer uptake metrics across various epithelial neoplasms, identify diagnostic pitfalls associated with 68Ga-FAPI PET\/CT, and evaluate the influence of 68Ga-FAPI PET\/CT staging results on changes in therapeutic intent compared to gold standard molecular imaging modalities. Methods: A total of 48 patients with biopsy-confirmed solid tumors underwent 77 68Ga-FAPI PET\/CT examinations for molecular imaging assessment, encompassing neoplasms originating from the gastrointestinal tract, head and neck, hepatobiliary system, pancreas, breast, and lung. Results: Notably, pancreaticobiliary tumors exhibited the highest tracer uptake, with mean maximum standardized uptake values (SUVmax) and tumor-to-background ratios (TBR) surpassing 10. A comparative sub-analysis of 68Ga-FAPI PET metrics in 20 treatment-na\u00efve patients revealed a significant correlation between 68Ga-FAPI uptake metrics and tumor grade (Spearman\u2019s rho 0.83; p = 0.00001). Importantly, the results from 68Ga-FAPI PET\/CT influenced treatment decisions in 35.5% of the cases, primarily resulting in an escalation of management plans. A total of 220 diagnostic challenges were identified across 88.3% of the scans, predominantly within the musculoskeletal system, attributed to degenerative changes (99 observations). Conclusions: This comprehensive analysis highlights the potential significance of 68Ga-FAPI PET\/CT in oncological imaging and treatment strategy, while also emphasizing the necessity for meticulous interpretation to mitigate diagnostic challenges.<\/jats:p>","DOI":"10.3390\/diagnostics15020218","type":"journal-article","created":{"date-parts":[[2025,1,20]],"date-time":"2025-01-20T04:04:12Z","timestamp":1737345852000},"page":"218","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":15,"title":["First Clinical Experience of 68Ga-FAPI PET\/CT in Tertiary Cancer Center: Identifying Pearls and Pitfalls"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0978-4716","authenticated-orcid":false,"given":"Akram","family":"Al-Ibraheem","sequence":"first","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"},{"name":"School of Medicine, University of Jordan, Al-Jubeiha, Amman 11942, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2009-5110","authenticated-orcid":false,"given":"Ahmed Saad","family":"Abdlkadir","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ula","family":"Al-Rasheed","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dhuha","family":"Al-Adhami","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Feras","family":"Istatieh","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-6851-0812","authenticated-orcid":false,"given":"Farah","family":"Anwar","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine, Warith International Cancer Institute, Karbala 56001, Iraq"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marwah","family":"Abdulrahman","sequence":"additional","affiliation":[{"name":"Department of Nuclear Medicine and PET\/CT, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rula","family":"Amarin","sequence":"additional","affiliation":[{"name":"Department of Medicine, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0153-9131","authenticated-orcid":false,"given":"Issa","family":"Mohamad","sequence":"additional","affiliation":[{"name":"Department of Radiation Oncology, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3443-5873","authenticated-orcid":false,"given":"Asem","family":"Mansour","sequence":"additional","affiliation":[{"name":"Department of Diagnostic Radiology, King Hussein Cancer Center (KHCC), Al-Jubeiha, Amman 11941, Jordan"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,1,19]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1573","DOI":"10.2174\/1389450119666180219124439","article-title":"Versatility of cancer associated fibroblasts: Commendable targets for anti-tumor therapy","volume":"19","author":"Khan","year":"2018","journal-title":"Curr. Drug Targets"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Joshi, R.S., Kanugula, S.S., Sudhir, S., Pereira, M.P., Jain, S., and Aghi, M.K. (2021). The Role of Cancer-Associated Fibroblasts in Tumor Progression. Cancers, 13.","DOI":"10.3390\/cancers13061399"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1016\/j.cpet.2023.02.007","article-title":"Fibroblast Activation Protein Inhibitor Theranostics: Early Clinical Translation","volume":"18","author":"Mori","year":"2023","journal-title":"PET Clin."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"622","DOI":"10.1053\/j.semnuclmed.2024.02.003","article-title":"Radiotheranostics Global Market and Future Developments","volume":"54","author":"Zimmermann","year":"2024","journal-title":"Semin. Nucl. Med."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"159","DOI":"10.1186\/s12943-023-01860-5","article-title":"Define cancer-associated fibroblasts (CAFs) in the tumor microenvironment: New opportunities in cancer immunotherapy and advances in clinical trials","volume":"22","author":"Zhang","year":"2023","journal-title":"Mol. Cancer"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"984","DOI":"10.1038\/s41417-021-00318-4","article-title":"Cancer-associated fibroblasts: Overview, progress, challenges, and directions","volume":"28","author":"Ping","year":"2021","journal-title":"Cancer Gene Ther."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1820","DOI":"10.1007\/s00259-020-04769-z","article-title":"Comparison of [68Ga] Ga-DOTA-FAPI-04 and [18F] FDG PET\/CT for the diagnosis of primary and metastatic lesions in patients with various types of cancer","volume":"47","author":"Chen","year":"2020","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"4089","DOI":"10.1007\/s00259-021-05378-0","article-title":"68Ga-FAPI-PET\/CT in patients with various gynecological malignancies","volume":"48","author":"Dendl","year":"2021","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"801","DOI":"10.2967\/jnumed.119.227967","article-title":"68Ga-FAPI PET\/CT: Tracer uptake in 28 different kinds of cancer","volume":"60","author":"Kratochwil","year":"2019","journal-title":"J. Nucl. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"4377","DOI":"10.1007\/s00259-021-05307-1","article-title":"Head-to-head intra-individual comparison of biodistribution and tumor uptake of 68Ga-FAPI and 18F-FDG PET\/CT in cancer patients","volume":"48","author":"Giesel","year":"2021","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e075680","DOI":"10.1136\/bmjopen-2023-075680","article-title":"68Ga-FAPI-04 positron emission tomography\/CT and laparoscopy for the diagnosis of occult peritoneal metastasis in newly diagnosed locally advanced gastric cancer: Study protocol of a single-centre prospective cohort study","volume":"14","author":"Zhang","year":"2024","journal-title":"BMJ Open"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"789","DOI":"10.1007\/s11307-022-01729-x","article-title":"Comparison of 68Ga-FAPI PET\/CT and 18FDG PET\/CT modalities in gastrointestinal system malignancies with peritoneal involvement","volume":"24","author":"Elboga","year":"2022","journal-title":"Mol. Imaging Biol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1148\/radiol.2020202469","article-title":"68Ga FAPI PET\/CT imaging in peritoneal carcinomatosis","volume":"297","author":"Guo","year":"2020","journal-title":"Radiology"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1053\/j.semnuclmed.2023.02.001","article-title":"FAPI-avid nonmalignant PET\/CT findings: An expedited systematic review","volume":"53","author":"Bentestuen","year":"2023","journal-title":"Semin. Nucl. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1097\/RLU.0000000000004802","article-title":"68Ga-FAPI PET\/CT imaging: Unveiling the hidden pitfalls","volume":"48","author":"Abdlkadir","year":"2023","journal-title":"Clin. Nucl. Med."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1055\/s-0044-1787886","article-title":"Fibroblast Activation Protein Inhibitor Theranostics: A Huge Opportunity with its Fair Share of Oncological Pitfalls","volume":"23","year":"2024","journal-title":"World J. Nucl. Med."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"3493","DOI":"10.1007\/s00259-021-05343-x","article-title":"Value of [68Ga] Ga-FAPI-04 imaging in the diagnosis of renal fibrosis","volume":"48","author":"Zhou","year":"2021","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1136","DOI":"10.2967\/jnumed.122.263922","article-title":"FAPI PET opens a new window to understanding immune-mediated inflammatory diseases","volume":"63","author":"Kuwert","year":"2022","journal-title":"J. Nucl. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"1674","DOI":"10.2967\/jnumed.123.266182","article-title":"FAPI PET\/CT Immune-Fibrosis Imaging for New Insights into Rheumatologic Disorders","volume":"64","author":"Schmidkonz","year":"2023","journal-title":"J. Nucl. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"3705","DOI":"10.1007\/s00259-022-05814-9","article-title":"[68Ga] Ga-FAPI-46 PET for non-invasive detection of pulmonary fibrosis disease activity","volume":"49","author":"Rosenkrans","year":"2022","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Al-Ibraheem, A., Badarneh, M., Abdlkadir, A.S., Al-Qasem, S., Ruzzeh, S., and Giammarile, F. (2024). Investigating the diffuse pancreatic expression of [68Ga]Ga-DOTA-FAPI: Location, timing, and molecular imaging approaches. Clin. Transl. Imaging.","DOI":"10.1007\/s40336-024-00638-z"},{"key":"ref_22","unstructured":"Edition, S., Edge, S., and Byrd, D. (2017). AJCC Cancer Staging Manual, American College of Surgeons."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Roma-Rodrigues, C., Mendes, R., Baptista, P.V., and Fernandes, A.R. (2019). Targeting tumor microenvironment for cancer therapy. Int. J. Mol. Sci., 20.","DOI":"10.3390\/ijms20040840"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"721","DOI":"10.1007\/s00259-021-05488-9","article-title":"FAP imaging in rare cancer entities\u2014first clinical experience in a broad spectrum of malignancies","volume":"49","author":"Dendl","year":"2022","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_25","first-page":"e56173","article-title":"Gallium-68-Labeled Fibroblast Activation Protein Inhibitor as an Alternative Radiotracer to Fluorine 18-Fluorodeoxyglucose: A Case Report of Rare Pulmonary Colloid Adenocarcinoma Diagnosed by PET\/CT","volume":"16","author":"Mansour","year":"2024","journal-title":"Cureus"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1049","DOI":"10.2967\/jnumed.122.265215","article-title":"Superior Tumor Detection for 68Ga-FAPI-46 Versus 18F-FDG PET\/CT and Conventional CT in Patients with Cholangiocarcinoma","volume":"64","author":"Pabst","year":"2023","journal-title":"J. Nucl. Med."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Lin, X., Li, Y., Wang, S., Zhang, Y., Chen, X., Wei, M., Zhu, H., Wu, A., Yang, Z., and Wang, X. (2022). Diagnostic value of [68Ga]Ga-FAPI-04 in patients with colorectal cancer in comparison with [18F]F-FDG PET\/CT. Front. Oncol., 12.","DOI":"10.3389\/fonc.2022.978506"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"7804","DOI":"10.1007\/s00330-024-10843-z","article-title":"Performance of fibroblast activating protein inhibitor PET imaging for pancreatic neoplasms assessment: A systematic review and meta-analysis","volume":"34","author":"Tang","year":"2024","journal-title":"Eur. Radiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1780","DOI":"10.1007\/s00259-022-06100-4","article-title":"Prognostic value of preoperative [68Ga]Ga-FAPI-04 PET\/CT in patients with resectable pancreatic ductal adenocarcinoma in correlation with immunohistological characteristics","volume":"50","author":"Ding","year":"2023","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1007\/s00259-020-04882-z","article-title":"Fibroblast imaging of hepatic carcinoma with 68Ga-FAPI-04 PET\/CT: A pilot study in patients with suspected hepatic nodules","volume":"48","author":"Shi","year":"2021","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e281","DOI":"10.1097\/RLU.0000000000004641","article-title":"Role of 68Ga-FAPI PET\/CT in assessing hepatobiliary malignancies: A prospective pilot study","volume":"48","author":"Rajaraman","year":"2023","journal-title":"Clin. Nucl. Med."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"3898","DOI":"10.1007\/s00259-022-05839-0","article-title":"Comparison of [68Ga] Ga-DOTA-FAPI-04 PET\/CT and [18F] FDG PET\/CT in colorectal cancer","volume":"49","author":"Can","year":"2022","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"5007","DOI":"10.1007\/s00330-023-09445-y","article-title":"The added value of [68Ga] Ga-DOTA-FAPI-04 PET\/CT in pancreatic cancer: A comparison to [18F] F-FDG","volume":"33","author":"Liu","year":"2023","journal-title":"Eur. Radiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"648","DOI":"10.1148\/radiol.213118","article-title":"Prospective comparison of 68Ga-FAPI versus 18F-FDG PET\/CT for tumor staging in biliary tract cancers","volume":"304","author":"Lan","year":"2022","journal-title":"Radiology"},{"key":"ref_35","first-page":"e313","article-title":"68Ga-FAPI PET\/CT provides a clear picture of a Klatskin tumor that 18F-FDG PET\/CT missed","volume":"48","author":"Amarin","year":"2022","journal-title":"Clin. Nucl. Med."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1910","DOI":"10.2967\/jnumed.122.264827","article-title":"68Ga-Labeled Fibroblast Activation Protein Inhibitor (68Ga-FAPI) PET for Pancreatic Adenocarcinoma: Data from the 68Ga-FAPI PET Observational Trial","volume":"64","author":"Kessler","year":"2023","journal-title":"J. Nucl. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2152","DOI":"10.1007\/s00259-023-06137-z","article-title":"Clinical prospective study of Gallium 68 (68Ga)\u2013labeled fibroblast-activation protein inhibitor PET\/CT in the diagnosis of biliary tract carcinoma","volume":"50","author":"Jinghua","year":"2023","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1016\/j.ijrobp.2023.08.019","article-title":"68Ga-FAPI-04 Positron Emission Tomography Distinguishes Malignancy From 18F-FDG-Avid Colorectal Lesions","volume":"118","author":"Shangguan","year":"2024","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1712","DOI":"10.2967\/jnumed.123.266046","article-title":"Impact of 68Ga-FAPI PET\/CT on Staging and Oncologic Management in a Cohort of 226 Patients with Various Cancers","volume":"64","author":"Koerber","year":"2023","journal-title":"J. Nucl. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"35","DOI":"10.1097\/RLU.0000000000004480","article-title":"Impact of 68Ga-FAPI-04 PET\/CT on Staging and Therapeutic Management in Patients with Digestive System Tumors","volume":"48","author":"Kosmala","year":"2023","journal-title":"Clin. Nucl. Med."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"490","DOI":"10.2214\/AJR.22.28402","article-title":"Head-To-Head Comparison of 68Ga-FAPI PET\/CT and FDG PET\/CT for the Detection of Peritoneal Metastases: Systematic Review and Meta-Analysis","volume":"220","author":"Gege","year":"2023","journal-title":"Am. J. Roentgenol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"4396","DOI":"10.1007\/s00259-021-05475-0","article-title":"State-of-the-art of FAPI-PET imaging: A systematic review and meta-analysis","volume":"48","author":"Sollini","year":"2021","journal-title":"Eur. J. Nucl. Med. Mol. Imaging"},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Chandekar, K.R., Prashanth, A., Vinjamuri, S., and Kumar, R. (2023). FAPI PET\/CT imaging\u2014An updated review. Diagnostics, 13.","DOI":"10.3390\/diagnostics13122018"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"890","DOI":"10.2967\/jnumed.121.262808","article-title":"Pitfalls and Common Findings in 68Ga-FAPI PET: A Pictorial Analysis","volume":"63","author":"Kessler","year":"2022","journal-title":"J. Nucl. Med."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"20220463","DOI":"10.1259\/bjr.20220463","article-title":"Non-oncologic incidental uptake on FAPI PET\/CT imaging","volume":"96","author":"Hotta","year":"2023","journal-title":"Br. J. Radiol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"20584601241307350","DOI":"10.1177\/20584601241307350","article-title":"Intense fibroblast activation protein inhibitor localization around the site of embolized gastroduodenal artery in a patient with metachronous pancreatic adenocarcinoma: A potential pitfall in positron imaging","volume":"13","author":"Abdlkadir","year":"2024","journal-title":"Acta Radiol. Open"},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Al-Ibraheem, A., Sweedat, D.A., Abdlkadir, A.S., Stanimirovi\u0107, D., and Dadgar, H. (2024). Stent-Induced [68Ga]Ga-FAPI Diffuse Expression in a Patient with Pancreatic Cancer: Navigating Non-oncologic Challenges. Nucl. Med. Mol. Imaging.","DOI":"10.1007\/s13139-024-00844-7"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1097\/RLU.0000000000001901","article-title":"Focal Autoimmune Pancreatitis Mimicking Pancreatic Cancer on FDG PET\/CT Imaging","volume":"43","author":"Zheng","year":"2018","journal-title":"Clin. Nucl. 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