Research ArticleClinical Investigation
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Impact of 68Ga-FAPI PET/CT on Staging and Oncologic Management in a Cohort of 226 Patients with Various Cancers

Stefan A. Koerber, Manuel Röhrich, Leon Walkenbach, Jakob Liermann, Peter L. Choyke, Christoph Fink, Cathrin Schroeter, Anna-Maria Spektor, Klaus Herfarth, Thomas Walle, Jeremie Calais, Hans-Ulrich Kauczor, Dirk Jaeger, Juergen Debus, Uwe Haberkorn and Frederik L. Giesel
Journal of Nuclear Medicine November 2023, 64 (11) 1712-1720; DOI: https://doi.org/10.2967/jnumed.123.266046

Article Figures & Data

Figures

  • Figure
  • FIGURE 1.
    FIGURE 1.

    Flowchart displaying distribution of exclusion criteria among 449 cancer patients who underwent 68Ga-FAPI PET/CT at University Hospital Heidelberg between June 2017 and February 2022 (left side) and fractions of included patients who could be analyzed with regard to TNM staging and clinical management.

  • FIGURE 2.
    FIGURE 2.

    Sankey plots displaying 68Ga-FAPI PET/CT–related changes in N and M staging of pancreatic cancer (A), head and neck tumors (B), and lung cancer (C). Gray boxes indicate identical staging based on GSI and 68Ga-FAPI PET/CT. Red curves indicate upstaging based on 68Ga-FAPI PET/CT compared with GSI. Green curves indicate downstaging based on 68Ga-FAPI PET/CT compared with GSI.

  • FIGURE 3.
    FIGURE 3.

    Relative distribution of 68Ga-FAPI PET–related changes in TNM staging (A) and clinical management (B) in different clinical settings (primary staging, follow-up, and progressive disease [PD]/recurrence). Bars are scales to 100% of patients analyzed per group.

  • FIGURE 4.
    FIGURE 4.

    Example images of 64-y-old woman with recurrent pancreatic ductal adenocarcinoma. (A) Maximum-intensity projection (MIP) of 68Ga-FAPI PET. (B) Axial 68Ga-FAPI PET/CT images and contrast-enhanced CT (ceCT) images of suggestive lesions (arrows: lesions 1 and 2, pulmonary metastasis and mediastinal lymph node metastasis; lesion 3, paraaortic lymph node metastasis) detected by 68Ga-FAPI PET. HU = Hounsfield units.

  • FIGURE 5.
    FIGURE 5.

    Example images of 78-y-old man with primary non–small cell lung cancer. (A) Maximum-intensity projection of 18F-FDG PET and 68Ga-FAPI PET. (B) Axial 18F-FDG PET/CT and 68Ga-FAPI PET/CT of suggestive lesions (arrows: lesion 1, cervical lymph node metastasis; lesion 2, non–small cell lung cancer with involvement of mediastinal lymph nodes; lesion 3, left adrenal mass). Although lesions 1 and 2 were clearly detectable by both PET scans, lesion 3 was 18F-FDG–avid but not confirmed by 68Ga-FAPI PET.

Tables

  • TABLE 1.

    GSI Modalities According to Type of Cancer

    EntityPatients (n)GSI
    Pancreatic ductal adenocarcinoma77ceCT or ceMRI
    Head and neck cancer29ceCT or ceMRI
    Lung cancer23ceCT (supplementary 18F-FDG PET/CT for 5 patients)
    Gliomas21ceMRI
    Colorectal cancer20ceCT or ceMRI (supplementary 18F-FDG PET/CT for 5 patients)
    Sarcomas11ceCT or ceMRI
    Esophageal cancer10ceCT (supplementary 18F-FDG PET/CT for 1 patient)
    Prostate cancer3ceCT and ceMRI (1) or 18F-PSMA PET/CT (2)
    Thyroid cancer5ceCT or ceMRI (supplementary 18F-FDG PET/CT for 3 patients, supplementary 68Ga-DOTATOC PET/CT for 1 patient)
    Ovarian cancer418F-FDG PET/CT and supplementary ceCT or ceMRI
    Breast cancer2ceCT (supplementary 18F-FDG PET/CT for 1 patient)
    Hepatic cancer4ceCT or ceMRI
    Cancer of unknown primary1ceCT
    Melanoma1ceCT and ceMRI
    Gastric cancer1ceCT
    Cervical cancer2ceCT or ceMRI
    Thymus cancer1ceCT
    Lymphoma1ceCT
    Gallbladder cancer2ceCT
    Chordoma1ceCT
    Renal cancer1ceCT
    Esthesioneuroblastoma1ceCT
    Cholangiocellular carcinoma4ceCT or ceMRI
    Appendix cancer1ceCT
    Total226

    • ceCT = contrast-enhanced CT; ceMRI = contrast-enhanced MRI.

  • TABLE 2.

    Changes in TNM Staging

    EntityPatients (n)StagingExplanatory note
    UnchangedMajor upMajor downMinor upMinor down
    PDAC774426610
    HNC29196211
    Lung cancer23105920In 2 cases, major upstaging and major downstaging at same time; in 1 case, major downstaging and minor upstaging at same time
    Gliomas21
    Colorectal cancer2010631
    Sarcomas11623
    Esophageal cancer1051211
    Thyroid cancer5311
    Others*30226300In 1 case, major up- and downstaging at same time
    Total number226119532962

    • ↵* Prostate cancer, ovarian cancer, breast cancer, hepatic cancer, cancer of unknown primary, melanoma, gastric cancer, cervical cancer, thymus cancer, lymphoma, gallbladder cancer, chordoma, renal cancer, esthesioneuroblastoma, cholangiocellular carcinoma, appendix cancer.

    • PDAC = pancreatic ductal adenocarcinoma; HNC = head and neck cancer.

  • TABLE 3.

    Changes in Oncologic Management

    EntityPatients (n)Clinical management
    UnchangedMajorMinorUnknown
    PDAC773472313
    HNC294124
    Lung cancer2381131
    Gliomas21615
    CRC209371
    Sarcomas115051
    Esophageal cancer1028
    Thyroid cancer541
    Others*3019281
    Total number226911410318

    • ↵* Prostate cancer, ovarian cancer, breast cancer, hepatic cancer, cancer of unknown primary, melanoma, gastric cancer, cervical cancer, thymus cancer, lymphoma, gallbladder cancer, chordoma, renal cancer, esthesioneuroblastoma, cholangiocellular carcinoma, appendix cancer.

    • PDAC = pancreatic ductal adenocarcinoma; HNC = head and neck cancer; CRC = colorectal cancer.

  • TABLE 4.

    Cohort Divided into 3 Subgroups: Primary Staging, Follow-up or Adjuvant Therapy, and Progressive Disease or Recurrence

    SubgroupPatients (n)TNM stagingOncologic management
    No changeDownstagingMixedUpstagingGliomasNo changeMinor changeMajor changeNo sufficient data
    Primary staging48265287113421
    Follow-up91541301954232413
    Progressive disease843692289373782
    Unclear3300001002
    Total226

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