Development of Fibroblast Activation Protein-Targeted Radiotracers with Improved Tumor Retention

FAP imaging in rare cancer entities-first clinical experience in a broad spectrum of malignancies

PURPOSE

68 Ga-FAPI (fibroblast activation protein inhibitor) is a rapidly evolving and highly promising radiotracer for PET/CT imaging, presenting excellent results in a variety of tumor entities, particularly in epithelial carcinomas. This retrospective analysis sought to evaluate the potential and impact of FAPI-PET/CT in rare cancer diseases with respect to improvement in staging and therapy, based on tracer uptake in normal organs and tumors.

MATERIAL AND METHODS

Fifty-five patients with rare tumor entities, defined by a prevalence of 1 person out of 2000 or less, received a 68 Ga-FAPI-PET/CT scan. Fourteen women and 41 men (median age 60) were included within the following subgroups: cancer of unknown primary (n = 10), head and neck cancer (n = 13), gastrointestinal and biliary-pancreatic cancer (n = 17), urinary tract cancer (n = 4), neuroendocrine cancer (n = 4), and others (n = 7). Tracer uptake was quantified by standardized uptake values SUVmax and SUVmean and the tumor-to-background ratio (TBR) was determined (SUVmax tumor/SUVmean organ).

RESULTS

In 20 out of 55 patients, the primary tumor was identified and 31 patients presented metastases (n = 88), characterized by a high mean SUVmax in primary (10.1) and metastatic lesions (7.6). The highest uptake was observed in liver metastases (n = 6) with a mean SUVmax of 9.8 and a high TBR of 8.7, closely followed by peritoneal carcinomatosis (n = 16) presenting a mean SUVmax of 9.8 and an excellent TBR of 29.6. In terms of the included subgroups, the highest uptake regarding mean SUVmax was determined in gastrointestinal and biliary-pancreatic cancer with 9.8 followed closely by urinary tract cancer with 9.5 and head and neck cancer (9.1).

CONCLUSION

Due to excellent tumor visualization and, thereby, sharp contrasts in terms of high TBRs in primary and metastatic lesions in different rare malignancies, 68 Ga-FAPI-PET/CT crystallizes as a powerful and valuable imaging tool, particularly with respect to epithelial carcinomas, and therefore an enhancement to standard diagnostics imaging methodologies. The realization of further and prospective studies is of large importance to confirm the potential of FAP imaging in oncology.

68Ga-FAPI as a Diagnostic Tool in Sarcoma: Data from the 68Ga-FAPI PET Prospective Observational Trial

Bone and soft-tissue sarcomas express fibroblast activation protein (FAP) on tumor cells and associated fibroblasts. Therefore, FAP is a promising therapeutic and diagnostic target. Novel radiolabeled FAP inhibitors (e.g., 68Ga-FAPI-46) have shown high tumor uptake on PET in sarcoma patients. Here, we report the endpoints of the 68Ga-FAPI PET prospective observational trial. Methods: Forty-seven patients with bone or soft-tissue sarcomas undergoing clinical 68Ga-FAPI PET were eligible for enrollment into the 68Ga-FAPI PET observational trial. Of these patients, 43 also underwent 18F-FDG PET. The primary study endpoint was the association between 68Ga-FAPI PET uptake intensity and histopathologic FAP expression analyzed with Spearman r correlation. Secondary endpoints were detection rate, positive predictive value (PPV), interreader reproducibility, and change in management. Datasets were interpreted by 2 masked readers. Results: The primary endpoint was met, and the association between 68Ga-FAPI PET uptake intensity and histopathologic FAP expression was significant (Spearman r = 0.43; P = 0.03). By histopathologic validation, PPV was 1.00 (95% CI, 0.87-1.00) on a per-patient and 0.97 (95% CI, 0.84-1.00) on a per-region basis. In cases with histopathologic validation, 27 of 28 (96%) confirmed patients and 32 of 34 (94%) confirmed regions were PET-positive, resulting in an SE of 0.96 (95% CI, 0.82-1.00) on a per-patient and 0.94 (95% CI, 0.80-0.99) on a per-region basis. The detection rate on a per-patient basis in 68Ga-FAPI and 18F-FDG PET was 76.6% and 81.4%, respectively. In 8 (18.6%) patients, 68Ga-FAPI PET resulted in an upstaging compared with 18F-FDG PET. 68Ga-FAPI PET readers showed substantial to almost perfect agreement for the defined regions (Fleiss κ: primary κ = 0.78, local nodal κ = 0.54, distant nodal κ = 0.91, lung κ = 0.86, bone κ = 0.69, and other κ = 0.65). Clinical management changed in 13 (30%) patients after 68Ga-FAPI PET. Conclusion: We confirm an association between tumoral 68Ga-FAPI PET uptake intensity and histopathologic FAP expression in sarcoma patients. Further, with masked readings and independent histopathologic validation, 68Ga-FAPI PET had a high PPV and sensitivity for sarcoma staging.

Design and Characterization of Fibroblast Activation Protein Targeted Pan-Cancer Imaging Agent for Fluorescence-Guided Surgery of Solid Tumors

Tumor-targeted fluorescent dyes have been shown to significantly improve a surgeon's ability to locate and resect occult malignant lesions, thereby enhancing a patient’s chances of long term survival. Although several...

Fibroblast Activation Protein-Specific PET/CT Imaging in Fibrotic Interstitial Lung Diseases and Lung Cancer: A Translational Exploratory Study

Interstitial lung diseases (ILDs) comprise over 200 parenchymal lung disorders. Among them, fibrosing ILDs, especially idiopathic pulmonary fibrosis, are associated with a poor prognosis, whereas some other ILDs, such as sarcoidosis, have a much better prognosis. A high proportion manifests as fibrotic ILD (fILD). Lung cancer (LC) is a frequent complication of fILD. Activated fibroblasts are crucial for fibrotic processes in fILD. The aim of this exploratory study was to evaluate the imaging properties of static and dynamic fibroblast activation protein (FAP) inhibitor (FAPI) PET/CT in various types of fILD and to confirm FAP expression in fILD lesions by FAP immunohistochemistry of human fILD biopsy samples and of lung sections of genetically engineered (Nedd4-2-/- ) mice with an idiopathic pulmonary fibrosislike lung disease. Methods: PET scans of 15 patients with fILD and suspected LC were acquired 10, 60, and 180 min after the administration of 150-250 MBq of a 68Ga-labeled FAPI tracer (FAPI-46). In 3 patients, dynamic scans over 40 min were performed instead of imaging after 10 min. The SUVmax and SUVmean of fibrotic lesions and LC were measured and CT-density-corrected. Target-to-background ratios (TBRs) were calculated. PET imaging was correlated with CT-based fibrosis scores. Time-activity curves derived from dynamic imaging were analyzed. FAP immunohistochemistry of 4 human fILD biopsy samples and of fibrotic lungs of Nedd4-2-/- mice was performed. Results: fILD lesions as well as LC showed markedly elevated 68Ga-FAPI uptake (density-corrected SUVmax and SUVmean 60 min after injection: 11.12 ± 6.71 and 4.29 ± 1.61, respectively, for fILD lesions and 16.69 ± 9.35 and 6.44 ± 3.29, respectively, for LC) and high TBR (TBR of density-corrected SUVmax and SUVmean 60 min after injection: 2.30 ± 1.47 and 1.67 ± 0.79, respectively, for fILD and 3.90 ± 2.36 and 2.37 ± 1.14, respectively, for LC). SUVmax and SUVmean decreased over time, with a stable TBR for fILD and a trend toward an increasing TBR in LC. Dynamic imaging showed differing time-activity curves for fILD and LC. 68Ga-FAPI uptake showed a positive correlation with the CT-based fibrosis index. Immunohistochemistry of human biopsy samples and the lungs of Nedd4-2-/- mice showed a patchy expression of FAP in fibrotic lesions, preferentially in the transition zone to healthy lung parenchyma. Conclusion:68Ga-FAPI PET/CT imaging is a promising new imaging modality for fILD and LC. Its potential clinical value for monitoring and therapy evaluation of fILD should be investigated in future studies.

Dimeric FAPI with potential for tumor theranostics

Radionuclide-labeled fibroblast activation protein inhibitors (FAPIs) are popular nuclear imaging probes in recent years. It's of great significance for tumor diagnosis and has great potential in tumor treatment. However, optimization of the probes is needed to further increase tumor uptake and prolong tumor retention for improved treatment efficacy and fewer side effects. In this issue of AJNMMI, Moon et al. reported two squaramide coupled FAPI conjugates (DOTA.(SA.FAPi)2 and DOTAGA.(SA.FAPi)2) and labeled them with 68Ga. The resulted tracers showed increased tumor accumulation and persistent retention, which led to an advance in PET imaging. The use of dimeric structures provides a feasible strategy to develop radiotherapeutic analogs of FAP inhibitors.

Fibroblast Activation Protein (FAP) targeting homodimeric FAP inhibitor radiotheranostics: a step to improve tumor uptake and retention time

Several radiopharmaceuticals targeting fibroblast activation protein (FAP) based on the highly potent FAP inhibitor UAMC1110 are currently under investigation. Pre-clinical as well as clinical research exhibited the potential of these imaging agents. However, the monomeric small molecules seemed to have a short retention time in the tumor in combination with fast renal clearance. Therefore, our strategy was to develop homodimeric systems having two FAP inhibitors to improve residence time and tumor accumulation. The homodimers with two squaramide coupled FAP inhibitor conjugates DOTA.(SA.FAPi)₂ and DOTAGA.(SA.FAPi)₂ were synthesized and radiochemically evaluated with gallium-68. [⁶⁸Ga]Ga-DOTAGA.(SA.FAPi)₂ was tested for its in vitro stability, lipophilicity and affinity properties. In addition, human PET/CT scans were performed for [⁶⁸Ga]Ga-DOTAGA.(SA.FAPi)₂ with a head-to-head comparison with [⁶⁸Ga]Ga-DOTA.SA.FAPi and [¹⁸F]FDG. Labeling with gallium-68 demonstrated high radiochemical yields. Inhibition measurements revealed excellent affinity and selectivity with low nanomolar IC₅₀ values for FAP. In PET/CT human studies, significantly higher tumor uptake as well as longer tumor retention could be observed for [⁶⁸Ga]Ga-DOTAGA.(SA.FAPi)₂ compared to [⁶⁸Ga]Ga-DOTA.SA.FAPi. Therefore, the introduction of the dimer led to an advance in human PET imaging indicated by increased tumor accumulation and prolonged retention times in vivo and thus, the use of dimeric structures could be the next step towards prolonged uptake of FAP inhibitors resulting in radiotherapeutic analogs of FAP inhibitors.

[18F]FAPI-42 PET imaging in cancer patients: optimal acquisition time, biodistribution, and comparison with [68Ga]Ga-FAPI-04

PURPOSE

[¹⁸F]FAPI-42 is a new fibroblast activation protein (FAP)-specific tracer used for cancer imaging. Here, we describe the optimal acquisition time and in vivo evaluation of [¹⁸F]FAPI-42 and compared intra-individual biodistribution, tumor uptake, and detection ability to [⁶⁸Ga]Ga-FAPI-04.

METHODS

A total of 22 patients with various types of cancer received [¹⁸F]FAPI-42 whole-body positron emission tomography/computed tomography (PET/CT). Among them, 4 patients underwent PET/CT scans, including an early dynamic 20-min, static 1-h, and static 2-h scans. The in vivo biodistribution in normal organs and tumor uptake were semiquantitatively evaluated using the standardized uptake value (SUV) and tumor-to-background ratio (TBR). Furthermore, both [¹⁸F]FAPI-42 and [⁶⁸Ga]Ga-FAPI-04 PET/CT were performed in 12 patients to compare biodistribution, tumor uptake, and tumor detection ability.

RESULTS

[¹⁸F]FAPI-42 uptake in the tumors was rapid and reached a high level with an average SUVmax of 15.8 at 18 min, which stayed at a similarly high level to 2 h. The optimal image acquisition time for [¹⁸F]FAPI-42 was determined to be 1 h postinjection. For tumor detection, [¹⁸F]FAPI-42 had a high uptake and could be clearly visualized in the lesions. Compared to [⁶⁸Ga]Ga-FAPI-04, [¹⁸F]FAPI-42 had the same detectability for 144 positive lesions. In addition, [¹⁸F]FAPI-42 showed a higher SUVmax in liver and bone lesions (P < 0.05) and higher TBRs in liver, bone, lymph node, pleura, and peritoneal lesions (all P < 0.05).

CONCLUSION

The present study demonstrates that the optimal image acquisition time of [¹⁸F]FAPI-42 is 1 h postinjection and that [¹⁸F]FAPI-42 exhibits comparable lesion detectability to [⁶⁸Ga]Ga-FAPI-04.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (ChiCTR2100045757).

Prostate-specific membrane antigen and fibroblast activation protein distribution in prostate cancer: preliminary data on immunohistochemistry and PET imaging

Introduction

Fibroblast activation protein (FAP) has been recently presented as new imaging target for malignant diseases and offers high contrast to surrounding normal tissue. FAP tracer uptake has been reported in various tumor entities. The aim of this study was to compare FAP and Prostate-specific membrane antigen (PSMA) expression in primary prostate cancer employing histological analyses and PET imaging in two small patient collectives.

Methods

Two independent small patient collectives were included in this study. For cohort A, data of 5 prostate cancer patients and 3 patients with benign prostate hyperplasia were included. Patients with prostate cancer were initially referred for PSMA PET staging. Radical prostatectomy was performed in all patients and prostate specimen of patients and biopsies of healthy controls were available for further evaluation. Histological workup included HE and immunohistochemistry using PSMA Ab, FAP Ab. Cohort B consists of 6 Patients with diagnosed mCRPC and available PSMA as well as FAP PET.

Results

Patients with proven prostate cancer infiltration exhibited strong positivity for PSMA in both primary tumors and lymph node metastases while stainings for FAP were found positive in some cases, but not all (2/5). Controls with BPH presented moderate PSMA staining and in one case also with a positive FAP staining (1/3). PET imaging with FAP seemed to result in more precise results in case of low PSMA expression than PSMA-PET.

Conclusions

While PSMA staining intensity is a valid indicator of prostate cancer in both primary tumor and lymph node metastases, the expression of FAP seems to be heterogeneous but not necessarily linked to cancer-associated fibroblasts. It is also present in inflammation-associated myofibroblasts. Therefore, its ultimate role in prostate cancer diagnosis remains a subject of discussion.

First-In-Human Results on the Biodistribution, Pharmacokinetics, and Dosimetry of [177Lu]Lu-DOTA.SA.FAPi and [177Lu]Lu-DOTAGA.(SA.FAPi)2

Recently, great interest has been gained regarding fibroblast activation protein (FAP) as an excellent target for theranostics. Several FAP inhibitor molecules such as [68Ga]Ga-labelled FAPI-02, 04, 46, and DOTA.SA.FAPi have been introduced and are highly promising molecular targets from the imaging point of view. FAP inhibitors introduced via bifunctional DOTA and DOTAGA chelators offer the possibility to complex Lutetium-177 due to an additional coordination site, and are suitable for theranostic applications owing to the increased tumor accumulation and prolonged tumor retention time. However, for therapeutic applications, very little has been accomplished, mainly due to residence times of the compounds. In an attempt to develop a promising therapeutic radiopharmaceutical, the present study aimed to evaluate and compare the biodistribution, pharmacokinetics, and dosimetry of [177Lu]Lu-DOTA.SA.FAPi, and [177Lu]Lu-DOTAGA.(SA.FAPi)2 in patients with various cancers. The FAPi agents, [177Lu]Lu-DOTA.SA.FAPi and [177Lu]Lu-DOTAGA.(SA.FAPi)2, were administered in two different groups of patients. Three patients (mean age-50 years) were treated with a median cumulative activity of 2.96 GBq (IQR: 2.2-3 GBq) [177Lu]Lu-DOTA.SA.FAPi and seven (mean age-51 years) were treated with 1.48 GBq (IQR: 0.6-1.5) of [177Lu]Lu-DOTAGA.(SA.FAPi)2. Patients in both the groups underwent serial imaging whole-body planar and SPECT/CT scans that were acquired between 1 h and 168 h post-injection (p.i.). The residence time and absorbed dose estimate in the source organs and tumor were calculated using OLINDA/EXM 2.2 software. Time versus activity graphs were plotted to determine the effective half-life (Te) in the whole body and lesions for both the radiotracers. Physiological uptake of [177Lu]Lu-DOTA.SA.FAPi was observed in the kidneys, colon, pancreas, liver, gall bladder, oral mucosa, lacrimal glands, and urinary bladder contents. Physiological biodistribution of [177Lu]Lu-DOTAGA.(SA.FAPi)2 involved liver, gall bladder, colon, pancreas, kidneys, and urinary bladder contents, lacrimal glands, oral mucosa, and salivary glands. In the [177Lu]Lu-DOTA.SA.FAPi group, the highest absorbed doses were noted in the kidneys (0.618 ± 0.015 Gy/GBq), followed by the colon (right colon: 0.472 Gy/GBq and left colon: 0.430 Gy/GBq). In the [177Lu]Lu-DOTAGA.(SA.FAPi)2 group, the colon received the highest absorbed dose (right colon: 1.160 Gy/GBq and left colon: 2.870 Gy/GBq), and demonstrated a significantly higher mean absorbed dose than [177Lu]Lu-DOTA.SA.FAPi (p < 0.011). [177Lu]Lu-DOTAGA.(SA.FAPi)2 had significantly longer median whole-body Te compared to that of [177Lu]Lu-DOTA.SA.FAPi [46.2 h (IQR: 38.5-70.1) vs. 23.1 h (IQR: 17.8-31.5); p-0.0167]. The Te of tumor lesions was significantly higher for [177Lu]Lu-DOTAGA.(SA.FAPi)2 compared to [177Lu]Lu-DOTA.SA.FAPi [86.6 h (IQR: 34.3-94.6) vs. 14 h (IQR: 12.8-15.5); p-0.0004]. The median absorbed doses to the lesions were 0.603 (IQR: 0.230-1.810) Gy/GBq and 6.70 (IQR: 3.40-49) Gy/GBq dose per cycle in the [177Lu]Lu-DOTA.SA.FAPi, and [177Lu]Lu-DOTAGA.(SA.FAPi)2 groups, respectively. The first clinical dosimetry study demonstrated significantly higher tumor absorbed doses with [177Lu]Lu-DOTAGA.(SA.FAPi)2 compared to [177Lu]Lu-DOTA.SA.FAPi. [177Lu]Lu-DOTAGA.(SA.FAPi)2 is safe and unveiled new frontiers to treat various end-stage cancer patients with a theranostic approach.

Nanoparticles for Cancer Diagnosis, Radionuclide Therapy and Theranostics

Nanoparticles have unique properties that can be exploited for cancer diagnosis and therapy. Intravenously injected nanoparticles accumulate predominantly in organs of the mononuclear phagocytic system, in addition to localizing in tumors and at sites of inflammation and infection. Accumulation in the liver and spleen lowers nanoparticles' ability to target pathological sites and compromises their use for radionuclide therapy. As described by Lee et al. in this issue of ACS Nano, radionuclide retention in liver and spleen can be greatly reduced by using liposomes that are surface-modified with esterase-cleavable radionuclide anchors. Because esterase activity is high in healthy tissues and low in tumors, the authors found that liposome-associated radioactivity rapidly cleared from the body and remained high only in tumors. The resulting images had high contrast-to-background ratios and remarkable tumor delineation. In this Perspective, we discuss these advances from early detection, cancer diagnosis, radionuclide therapy, and theranostics points of view. We outline the current clinical landscape of radionuclide targeting, imaging and therapy, and reflect on the roles that nanoparticles can play in these applications. We highlight the potential of nanoparticles that are responsive to endogenous stimuli for intraoperative imaging and, particularly, for individualized and improved radionuclide treatment. Taking these advances into account, future studies exploring the robustness and the clinical feasibility of nanomedicine-based radiotheranostic probes are eagerly awaited.

Radioligands Targeting Fibroblast Activation Protein (FAP)

Simple Summary

FAP-targeted radiotracers, recently introduced in cancer treatment, accumulate in Cancer-Associated Fibroblasts (CAFs). CAFs are present in tumor lesions but do not correspond to genuine cancer cells, although they behave in an abnormal and disease-promoting manner. One of their characteristic features, the expression of the surface protein FAP, can be utilized to discriminate between cancerous and healthy tissues. By the choice of an appropriate radionuclide, FAP-targeted tracers can be used for imaging or therapy in many cancer types. Therefore, the first successful application of FAP-targeted imaging has led to an enormous and growing interest in nuclear medicine and radiopharmacy.

Abstract

Targeting fibroblast activation protein (FAP) in cancer-associated fibroblasts (CAFs) has attracted significant attention in nuclear medicine. Since these cells are present in most cancerous tissues and FAP is rarely expressed in healthy tissues, anti-FAP tracers have a potential as pan-tumor agents. Compared to the standard tumor tracer [¹⁸F]FDG, these tracers show better tumor-to-background ratios (TBR) in many indications. Unlike [¹⁸F]FDG, FAP-targeted tracers do not require exhausting preparations, such as dietary restrictions on the part of the patient, and offer the possibility of radioligand therapy (RLT) in a theragnostic approach. Although a radiolabeled antibody was clinically investigated as early as the 1990s, the breakthrough event for FAP-targeting in nuclear medicine was the introduction and clinical application of the so-called FAPI-tracers in 2018. From then, the development and application of FAP-targeted tracers became hot topics for the radiopharmaceutical and nuclear medicine community, and attracted the interest of pharmaceutical companies. The aim of this review is to provide a comprehensive overview of the development of FAP-targeted radiopharmaceuticals and their application in nuclear medicine.

Fibroblast-Activated Protein Inhibitor PET/CT: Cancer Diagnosis and Management

Fibroblast activation protein (FAP), overexpressed on cancer-associated fibroblasts (CAFs), is a novel target for molecular imaging of various tumors. Recently, the development of several small-molecule FAP inhibitors for radiolabeling with 68Ga has resulted in the emergence of studies evaluating its clinical role in cancer imaging. Preliminary findings have demonstrated that, in contrast to radiotracers taking advantage of cancer-specific targets such as PSMA and DOTATATE, FAPs as a target are the most promising that can compete with 18FDG in terms of widespread indications. They also have the potential to overcome the shortcomings of 18FDG, particularly false-positive uptake due to inflammatory or infectious processes, low sensitivity in certain cancer types, and radiotherapy planning. In addition, the attractive theranostic properties may facilitate the treatment of many refractory cancers. This review summarizes the current FAP variants and related clinical studies, focusing on radiopharmacy, dosimetry, and diagnostic and theranostic applications.

Fatty acid-conjugated radiopharmaceuticals for fibroblast activation protein-targeted radiotherapy

INTRODUCTION

Radiopharmaceuticals that target cancer-associated fibroblasts (CAFs) have become an increasingly attractive strategy for cancer theranostics. Recently, a series of fibroblast activation protein inhibitor (FAPI)-based radiopharmaceuticals have been successfully applied to the diagnosis of a variety of cancers and exhibited excellent tumor selectivity. Nevertheless, CAF-targeted radionuclide therapy encounters difficulties in cancer treatment, as the tumor uptake and retention of FAPIs are insufficient. To meet this challenge, we tried to conjugate albumin-binding moiety to FAPI molecule for prolonged circulation that may increase the accumulation and retention of radiopharmaceuticals in tumor.

METHODS

Two fatty acids, lauric acid (C12) and palmitic acid (C16), were conjugated to FAPI-04 to give two albumin-binding FAPI radiopharmaceuticals, denoted as FAPI-C12 and FAPI-C16, respectively. They had been radiolabeled with gallium-68, yttrium-86, and lutecium-177 for stability study, binding affinity assay, PET and SPECT imaging, biodistribution, and radionuclide therapy study to systematically evaluate their potential for CAF-targeted radionuclide therapy.

RESULTS

FAPI-C12 and FAPI-C16 showed high binding affinity to FAP with the IC₅₀ of 6.80 ± 0.58 nM and 5.06 ± 0.69 nM, respectively. They were stable in both saline and plasma. The tumor uptake of [⁶⁸Ga]Ga-FAPI-04 decreased by 56.9% until 30 h after treated with FAPI-C16 before, and the uptakes of [⁸⁶Y]Y-FAPI-C12 and [⁸⁶Y]Y-FAPI-C16 in HT-1080-FAP tumor were both much higher than that of HT-1080-Vehicle tumor which identified the high FAP specific of these two radiopharmaceuticals. Both FAPI-C12 and FAPI-C16 showed notably longer circulation and significantly enhanced tumor uptake than those of FAPI-04. [¹⁷⁷Lu]Lu-FAPI-C16 had the higher tumor uptake at both 24 h (11.22 ± 1.18%IA/g) and 72 h (6.50 ± 1.19%IA/g) than that of [¹⁷⁷Lu]Lu-FAPI-C12 (24 h, 7.54 ± 0.97%IA/g; 72 h, 2.62 ± 0.65%IA/g); both of them were much higher than [¹⁷⁷Lu]Lu-FAPI-04 with the value of 1.24 ± 0.54%IA/g at 24 h after injection. Significant tumor volume inhibition of [¹⁷⁷Lu]Lu-FAPI-C16 at the high activity of 29.6 MBq was observed, and the median survival was 28 days which was much longer than that of the [¹⁷⁷Lu]Lu-FAPI-04 treated group of which the median survival was only 10 days.

CONCLUSION

This proof-of-concept study validates the hypothesis that conjugation of albumin binders may shift the pharmacokinetics and enhance the tumor uptake of FAPI-based radiopharmaceuticals. This could be a general strategy to transform the diagnostic FAP-targeted radiopharmaceuticals into their therapeutic pairs.

Synthesis and Preliminary Evaluation of 131I-Labeled FAPI Tracers for Cancer Theranostics

As an excellent target for cancer theranostics, fibroblast activation protein (FAP) has become an attractive focus in cancer research. A class of FAP inhibitors (FAPIs) with a N-(4-quinolinoyl)-Gly-(2-cyanopyrrolidine) scaffold were developed, which displayed nanomolar affinity and high selectivity. Compared with ⁹⁰Y, ¹⁷⁷Lu, ²²⁵Ac, and ¹⁸⁸Re, ²¹¹At seems to be more favored as a therapeutic candidate for FAPI tracers which have fast washout and short retention in tumor sites. Thus, the current study reported the synthesis of two FAPI precursors for ²¹¹At and ¹³¹I labeling and the preliminary evaluation of ¹³¹I-labeled FAPI analogues for cancer theranostics. FAPI variants with stannyl precursors were successfully synthesized and labeled with ¹³¹I using a radioiododestannylation reaction. Two radioactive tracers were obtained with high radiochemical purity over 99% and good radiochemical yields of 58.2 ± 1.78 and 59.5 ± 4.44% for ¹³¹I-FAPI-02 and ¹³¹I-FAPI-04, respectively. Both tracers showed high specific binding to U87MG cells in comparison with little binding to MCF-7 cells. Compared to ¹³¹I-FAPI-02, ¹³¹I-FAPI-04 exhibited higher affinity, more intracellular uptake, and longer retention time in vitro. Biodistribution studies revealed that both tracers were mainly excreted through the kidneys as well as the hepatobiliary pathway due to their high lipophilicity. In addition, higher accumulation, longer dwell time, and increased tumor-to-organ ratios were achieved by ¹³¹I-FAPI-04, which was clearly demonstrated by SPECT/CT imaging. Furthermore, intratumor injection of ¹³¹I-FAPI-04 significantly suppressed the tumor growth in U87MG xenograft mice without significant toxicity observed. The above results implied that FAP-targeted alpha endoradiotherapy (specific to ²¹¹At) should be used to treat tumors in the near future, considering the chemical similarity between iodine and astatine can ensure the labeling of the latter onto the designed FAPIs.

Feasibility and Therapeutic Potential of 177Lu-Fibroblast Activation Protein Inhibitor-46 for Patients With Relapsed or Refractory Cancers: A Preliminary Study

INTRODUCTION

Fibroblast activation protein (FAP) is a member of the serine protease family and has a high expression in the stroma of approximately 90% of epithelial malignancies. The present investigation aimed to assess the feasibility, safety, and dosimetry data of 177Lu-FAPI-46 in diverse malignancies.

PATIENTS AND METHODS

Patients with advanced cancers with nonoperable tumors, or tumors refractory to conventional therapies, were enrolled. Treatment included escalating doses of 177Lu-FAPI-46 (1.85-4.44 GBq) per cycle using a combination of clinical and statistical expertise design, and intervals of 4 to 6 weeks were considered between the cycles. Biodistribution and dosimetry were examined by whole-body scans. We applied the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 to measure peptide-targeted radionuclide therapy (PTRT)-associated toxicity.

RESULTS

A total of 21 patients (11 females and 10 males) with a median age of 50 years (range, 6-79 years) were investigated. Of 21 participants, 18 cases were selected for PTRT. Overall, 36 PTRT cycles were performed. The median number of PTRT cycles and the median injected amount of activity in each cycle were 2 and 3.7 GBq, respectively. The dosimetric analysis revealed median absorbed doses of 0.026, 0.136, 0.886, and 0.02 with ranges of 0.023-0.034, 0.001-0.2, 0.076-1.39, and 0.002-0.2 mGy/MBq for the whole body, liver, kidneys, and spleen, respectively. The therapy was well tolerated in almost all patients.

CONCLUSIONS

The findings of this preliminary investigation might indicate the potential feasibility and safety of PTRT using 177Lu-FAPI-46 for different aggressive tumors. Moreover, the current study could be beneficial in determining the suitable amount of activity for a phase 2 study.

Pitfalls and common findings in 68Ga-FAPI-PET - A pictorial analysis

Introduction: Fibroblast activation protein inhibitor positron emission tomography (FAPI-PET) is a new tool in the diagnostic workup of cancer. With growing volume of applications pitfalls and common findings need to be considered for Ga-68-FAPI-PET image interpretation. The aim of this study was to summarize common findings and report pitfalls in Ga-68-FAPI-PET. Methods and materials: 91 patients underwent whole-body PET/CT with either FAPI-04 (N = 25) or FAPI-46 (N = 66). Findings were rated in a consensus session of two experienced readers. Pitfalls and common findings were defined as focal or localized uptake above background and categorized as unspecific / non-malignant and grouped into degenerative, muscular, scarring / wound-healing, uterine, mammary glands and head-and-neck findings. Frequency of findings was reported on a per-patient and per-group basis and SUV_max, SUVmean and SUVpeak was measured. Results: Non-tumor specific tracer uptake was found in 81.3 % of patients. The most frequent finding was tracer uptake in degenerative lesions (51.6%) with mean SUV_max 7.7 ± 2.9 and head-and-neck (45.1%) findings. Except for salivary glands, the uptake values did not differ between 10 and 60 min p.i. in most findings. Uterine uptake was found in most women (66.7%) with mean SUV_max 12.2 ± 7.3 and uptake correlated negatively with age (SUV_max r = -0.6, p<0.01; SUVpeak r = -0.57, p<0.01; SUVmean r = -0.58, p<0.01). Conclusion: Pitfalls include non-tumor specific Ga-68-FAPI uptake in degenerative lesions, muscle, head-and-neck, scarring, mammary glands or uterus. Here we summarize findings to inform readers at centers introducing Ga-68-FAPI-PET to avoid common mistakes.

New Frontiers in Cancer Imaging and Therapy Based on Radiolabeled Fibroblast Activation Protein Inhibitors: A Rational Review and Current Progress

Over the past decade, the tumor microenvironment (TME) has become a new paradigm of cancer diagnosis and therapy due to its unique biological features, mainly the interconnection between cancer and stromal cells. Within the TME, cancer-associated fibroblasts (CAFs) demonstrate as one of the most critical stromal cells that regulate tumor cell growth, progression, immunosuppression, and metastasis. CAFs are identified by various biomarkers that are expressed on their surfaces, such as fibroblast activation protein (FAP), which could be utilized as a useful target for diagnostic imaging and treatment. One of the advantages of targeting FAP-expressing CAFs is the absence of FAP expression in quiescent fibroblasts, leading to a controlled targetability of diagnostic and therapeutic compounds to the malignant tumor stromal area using radiolabeled FAP-based ligands. FAP-based radiopharmaceuticals have been investigated strenuously for the visualization of malignancies and delivery of theranostic radiopharmaceuticals to the TME. This review provides an overview of the state of the art in TME compositions, particularly CAFs and FAP, and their roles in cancer biology. Moreover, relevant reports on radiolabeled FAP inhibitors until the year 2021 are highlighted-as well as the current limitations, challenges, and requirements for those radiolabeled FAP inhibitors in clinical translation.

FAP and FAPI-PET/CT in Malignant and Non-Malignant Diseases: A Perfect Symbiosis?

A fibroblast activation protein (FAP) is an atypical type II transmembrane serine protease with both endopeptidase and post-proline dipeptidyl peptidase activity. FAP is overexpressed in cancer-associated fibroblasts (CAFs), which are found in most epithelial tumors. CAFs have been implicated in promoting tumor cell invasion, angiogenesis and growth and their presence correlates with a poor prognosis. However, FAP can generally be found during the remodeling of the extracellular matrix and therefore can be detected in wound healing and benign diseases. For instance, chronic inflammation, arthritis, fibrosis and ischemic heart tissue after a myocardial infarction are FAP-positive diseases. Therefore, quinoline-based FAP inhibitors (FAPIs) bind with a high affinity not only to tumors but also to a variety of benign pathologic processes. When these inhibitors are radiolabeled with positron emitting radioisotopes, they provide new diagnostic and prognostic tools as well as insights into the role of the microenvironment in a disease. In this respect, they deliver additional information beyond what is afforded by conventional FDG PET scans that typically report on glucose uptake. Thus, FAP ligands are considered to be highly promising novel tracers that offer a new diagnostic and theranostic potential in a variety of diseases.

Rational Design, Pharmacomodulation, and Synthesis of [68Ga]Ga-Alb-FAPtp-01, a Selective Tumor-Associated Fibroblast Activation Protein Tracer for PET Imaging of Glioma

Dynamic changes in the tumor-associated fibroblast activation protein (FAP) expression in tumors of different stages may be helpful for prognostic evaluation and treatment response monitoring, making this protein a promising surveillance biomarker for timely diagnosis of malignant tumors and effective planning of patient care. To prospectively verify the diagnostic efficacy value of the developed FAP tracers, [⁶⁸Ga]Ga-FAPtp and [⁶⁸Ga]Ga-Alb-FAPtp-01, dynamic/static positron emission tomography (PET)/computed tomography scans were acquired for tumor-targeting studies in vivo and in comparison with the well-established clinically used tracer [⁶⁸Ga]Ga-FAPI-04. The optimized rationally designed FAP-targeting PET tracer, [⁶⁸Ga]Ga-Alb-FAPtp-01, with albumin-binding capability demonstrated prominent tumor uptake over time. The mean standard uptake value (SUV) and the tumor/muscle (T/M) ratio were as high as 1.775 ± 0.179 SUV and T/M = 5.9, 1.533 ± 0.222 SUV and T/M = 6.7, and 1.425 ± 0.204 SUV and T/M = 9.5, respectively, at 1, 2, and 3 h. Its improved tumor uptake and pharmacokinetics suggest that the [⁶⁸Ga]Ga-Alb-FAPtp-01 tracer can noninvasively detect FAP activation in vivo, permitting a precise definition of its roles in tumors of different stages and yielding insights regarding FAP-targeted radiotherapeutic strategies at the molecular level.

Synthesis, preclinical evaluation, and a pilot clinical PET imaging study of 68Ga-labeled FAPI dimer

Cancer-associated fibroblasts (CAFs) are crucial components of the tumor microenvironment. Fibroblast activation protein (FAP) is overexpressed in CAFs. FAP-targeted molecular imaging agents, including FAP inhibitor (FAPI)-04 and FAPI-46, have shown promising results in tumor diagnosis. However, these molecules have relatively short tumor-retention time for peptide-targeted radionuclide therapy applications. We aimed to design a ⁶⁸Ga-labeled FAPI dimer (denoted as ⁶⁸Ga-DOTA-2P(FAPI)2) to optimize the pharmacokinetics and evaluate whether this form is more effective than its monomeric analogs. Methods: ⁶⁸Ga-DOTA-2P(FAPI)2 was synthesized based on the quinoline-based FAPI variants (FAPI-46), and its binding properties were assayed in CAFs. Preclinical pharmacokinetics was determined in FAP-positive patient-derived xenografts (PDXs) using small-animal PET and biodistribution experiments. The effective dosimetry of ⁶⁸Ga-DOTA-2P(FAPI)2 was evaluated in three healthy volunteers, and PET/ CT imaging of ⁶⁸Ga-FAPI-46 and ⁶⁸Ga-DOTA-2P(FAPI)2 was performed in three cancer patients. Results: ⁶⁸Ga-DOTA-2P(FAPI)2 was stable in phosphate-buffered saline and fetal bovine serum for 4 h. The FAPI dimer showed high affinity and specificity for FAP in-vitro and in-vivo. The tumor uptake of ⁶⁸Ga-DOTA-2P(FAPI)2 was approximately two-fold stronger than that of ⁶⁸Ga-FAPI-46 in PDXs, while the healthy organs showed low tracer uptake and fast body clearance. The effective dose of ⁶⁸Ga-DOTA-2P(FAPI)2 was 1.19E-02 mSv/MBq, calculated using OLINDA. Finally, PET/CT scans in three cancer patients revealed higher intratumoral uptake of ⁶⁸Ga-DOTA-2P(FAPI)2 than that of ⁶⁸Ga-FAPI-46 in all tumor lesions (maximum standardized uptake value: 8.1-39.0 vs. 1.7-24.0, respectively; P < 0.001). Conclusion: ⁶⁸Ga-DOTA-2P(FAPI)2 has increased tumor uptake and retention properties compared to ⁶⁸Ga-FAPI-46, and it could be a promising tracer for both diagnostic imaging and targeted therapy of malignant tumors with positive expression of FAP.

Fibroblast activation protein targeted therapy using [177Lu]FAPI-46 compared with [225Ac]FAPI-46 in a pancreatic cancer model

Purpose

Fibroblast activation protein (FAP), which has high expression in cancer-associated fibroblasts of epithelial cancers, can be used as a theranostic target. Our previous study used ⁶⁴Cu and ²²⁵Ac-labelled FAP inhibitors (FAPI-04) for a FAP-expressing pancreatic cancer xenograft imaging and therapy. However, the optimal therapeutic radionuclide for FAPI needs to be investigated further. In this study, we evaluated the therapeutic effects of beta-emitter (¹⁷⁷Lu)-labelled FAPI-46 and alpha-emitter (²²⁵Ac)-labelled FAPI-46 in pancreatic cancer models.

Methods

PET scans (1 h post injection) were acquired in PANC-1 xenograft mice (n = 9) after the administration of [¹⁸F]FAPI-74 (12.4 ± 1.7 MBq) for the companion imaging. The biodistribution of [¹⁷⁷Lu]FAPI-46 and [²²⁵Ac]FAPI-46 were evaluated in the xenograft model (total n = 12). For the determination of treatment effects, [¹⁷⁷Lu]FAPI-46 and [²²⁵Ac]FAPI-46 were injected into PANC-1 xenograft mice at different doses: 3 MBq (n = 6), 10 MBq (n = 6), 30 MBq (n = 6), control (n = 4) for [¹⁷⁷Lu]FAPI-46, and 3 kBq (n = 3), 10 kBq (n = 2), 30 kBq (n = 6), control (n = 7) for [²²⁵Ac]FAPI-46. Tumour sizes and body weights were followed.

Results

[¹⁸F]FAPI-74 showed rapid clearance by the kidneys and high accumulation in the tumour and intestine 1 h after administration. [¹⁷⁷Lu]FAPI-46 and [²²⁵Ac]FAPI-46 also showed rapid clearance by the kidneys and relatively high accumulation in the tumour at 3 h. Both [¹⁷⁷Lu]FAPI-46 and [²²⁵Ac]FAPI-46 showed tumour-suppressive effects, with a mild decrease in body weight. The treatment effects of [¹⁷⁷Lu]FAPI-46 were relatively slow but lasted longer than those of [²²⁵Ac]FAPI-46.

Conclusion

This study suggested the possible application of FAPI radioligand therapy in FAP-expressing pancreatic cancer. Further evaluation is necessary to find the best radionuclide with shorter half-life, as well as the combination with therapies targeting tumour cells directly.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05554-2.

Research Progress on Dipeptidyl Peptidase Family: Structure, Function and Xenobiotic Metabolism

Prolyl-specific peptidases or proteases, including Dipeptidyl Peptidase 2, 4, 6, 8, 9, 10, Fibroblast Activation Protein, prolyl endopeptidase and prolyl carboxypeptidase, belong to the dipeptidyl peptidase family. In human physiology and anatomy, they have homology amino acid sequences, similarities in structure, but play distinct functions and roles. Some of them also play important roles in the metabolism of drugs containing endogenous peptides, xenobiotics containing peptides, and exogenous peptides. The major functions of these peptidases in both the metabolism of human health and bioactive peptides are of significant importance in the development of effective inhibitors to control the metabolism of endogenous bioactive peptides. The structural characteristics, distribution of tissue, endogenous substrates, and biological functions were summarized in this review. Furthermore, the xenobiotics metabolism of the dipeptidyl peptidase family is illustrated. All the evidence and information summarized in this review would be very useful for researchers to extend the understanding of the proteins of these families and offer advice and assistance in physiology and pathology studies.

Fibroblast Activation Protein-α as a Target in the Bench-to-Bedside Diagnosis and Treatment of Tumors: A Narrative Review

Fibroblast activation protein-α (FAP) is a type II integral serine protease that is specifically expressed by activated fibroblasts. Cancer-associated fibroblasts (CAFs) in the tumor stroma have an abundant and stable expression of FAP, which plays an important role in promoting tumor growth, invasion, metastasis, and immunosuppression. For example, in females with a high incidence of breast cancer, CAFs account for 50–70% of the cells in the tumor’s microenvironment. CAF overexpression of FAP promotes tumor development and metastasis by influencing extracellular matrix remodeling, intracellular signaling, angiogenesis, epithelial-to-mesenchymal transition, and immunosuppression. This review discusses the basic biological characteristics of FAP and its applications in the diagnosis and treatment of various cancers. We review the emerging basic and clinical research data regarding the use of nanomaterials that target FAP.

18F-labeled tracers targeting fibroblast activation protein

Background

Cancer-associated fibroblasts are found in the stroma of epithelial tumors. They are characterized by overexpression of the fibroblast activation protein (FAP), a serine protease which was already proven as attractive target for chelator-based theranostics. Unfortunately, the value of gallium-68 labeled tracers is limited by their batch size and the short nuclide half-life. To overcome this drawback, radiolabeling with aluminum fluoride complexes and 6-fluoronicotinamide derivatives of the longer-lived nuclide fluorine-18 was established. The novel compounds were tested for their FAP-specific binding affinity. Uptake and binding competition were studied in vitro using FAP expressing HT-1080 cells. HEK cells transfected with the closely related dipeptidyl peptidase-4 (HEK-CD26) were used as negative control. Small animal positron emission tomography imaging and biodistribution experiments were performed in HT-1080-FAP xenografted nude mice. [¹⁸F]AlF-FAPI-74 was selected for PET/CT imaging in a non-small cell lung cancer (NSCLC) patient.

Results

In vitro, ¹⁸F-labeled FAPI-derivatives demonstrated high affinity (EC₅₀ = < 1 nm to 4.2 nm) and binding of up to 80% to the FAP-expressing HT1080 cells while no binding to HEK-CD26 cells was observed. While small animal PET imaging revealed unfavorable biliary excretion of most of the ¹⁸F-labeled compounds, the NOTA bearing compounds [¹⁸F]AlF-FAPI-74 and -75 achieved good tumor-to-background ratios, as a result of their preferred renal excretion. These two compounds showed the highest tumor accumulation in PET imaging. The organ distribution values of [¹⁸F]AlF-FAPI-74 were in accordance with the small animal PET imaging results. Due to its less complex synthesis, fast clearance and low background values, [¹⁸F]AlF-FAPI-74 was chosen for clinical imaging. PET/CT of a patient with metastasized non-small cell lung cancer (NSCLC), enabled visualization of the primary tumor and its metastases at the hepatic portal and in several bones. This was accompanied by a rapid clearance from the blood pool and low background in healthy organs.

Conclusion

[¹⁸F]AlF-labeled FAPI derivatives represent powerful tracers for PET. Owing to an excellent performance in PET imaging, FAPI-74 can be regarded as a promising precursor for [¹⁸F]AlF-based FAP-imaging.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41181-021-00144-x.

Increased 68Ga-FAPI-04 Uptake in Schmorl Node in a Patient With Gastric Cancer

ABSTRACT

A 78-year-old man with a newly diagnosed gastric adenocarcinoma underwent 18F-FDG and 68Ga-FAPI-04 PET/CT before treatment. Both 18F-FDG and 68Ga-FAPI-04 PET/CT demonstrated intense radioactivity in the gastric cancer. However, the benign Schmorl node in the inferior endplate of the T5 vertebrae showed increased uptake of 68Ga-FAPI-04, which was not FDG avid. Two months after radical gastrectomy of the gastric cancer (pT1aN0M0, IA), a follow-up CT showed that the Schmorl node in T5 vertebrae remained unchanged.

Primary Central Nervous System Lymphoma Revealed by 68Ga-FAPI and 18F-FDG PET/CT

ABSTRACT

A 67-year-old woman presented with left limb weakness, facial paralysis, and unsteady gait for 1 month. Brain MRI detected a mass in the right frontal lobe with prominent peritumoral edema, suggesting a malignant brain tumor. In 18F-FDG PET/CT, the mass was very FDG avid, and 68Ga-FAPI PET/CT showed the mass had heterogeneously mild to moderate increased uptake of the tracer. Histopathological examination after surgical resection of the mass confirmed the diagnosis of diffuse large B-cell lymphoma. The current case indicated the existence of fibrosis in the lymphoma lesion to some extent.

Theranostic Approach in Breast Cancer: A Treasured Tailor for Future Oncology

ABSTRACT

Breast cancer is the most frequent invasive malignancy and the second major cause of cancer death in female subjects mostly due to the considerable diagnostic delay and failure of therapeutic strategies. Thus, early diagnosis and possibility to monitor response to the treatment are of utmost importance. Identification of valid biomarkers, in particular new molecular therapeutic targets, that would allow screening, early patient identification, prediction of disease aggressiveness, and monitoring response to the therapeutic regimen has been in the focus of breast cancer research during recent decades. One of the intensively developing fields is nuclear medicine combining molecular diagnostic imaging and subsequent (radio)therapy in the light of theranostics. This review aimed to survey the current status of preclinical and clinical research using theranostic approach in breast cancer patients with potential to translate into conventional treatment strategies alone or in combination with other common treatments, especially in aggressive and resistant types of breast cancer. In addition, we present 5 patients with breast cancer who were refractory or relapsed after conventional therapy while presumably responded to the molecular radiotherapy with 177Lu-trastuzumab (Herceptin), 177Lu-DOTATATE, and 177Lu-FAPI-46.

An Impressive Approach in Nuclear Medicine: Theranostics

Radiometal-based theranostics or theragnostics, first used in the early 2000s, is the combined application of diagnostic and therapeutic agents that target the same molecule, and represents a considerable advancement in nuclear medicine. One of the promising fields related to theranostics is radioligand therapy. For instance, the concepts of targeting the prostate-specific membrane antigen (PSMA) for imaging and therapy in prostate cancer, or somatostatin receptor targeted imaging and therapy in neuroendocrine tumors (NETs) are part of the field of theranostics. Combining targeted imaging and therapy can improve prognostication, therapeutic decision-making, and monitoring of the therapy.

The clinical application of 18F-FDG PET/CT in pancreatic cancer: a narrative review

Pancreatic cancer is one of the worst prognoses of all malignant tumors, with an annual incidence near its annual mortality rate. To improve the prognosis of patients with pancreatic cancer, it is essential to diagnose and evaluate pancreatic cancer early. Imaging examinations play an essential role in tumor detection, staging, and surgical resection assessment and can provide reliable evidence for the diagnosis and treatment of pancreatic cancer. Currently, imaging techniques commonly used for pancreatic cancer include endoscopic ultrasound (EUS), conventional ultrasound, magnetic resonance imaging (MRI), multidetector spiral computed tomography (MDCT), positron emission tomography/computed tomography (PET/CT), and others PET/CT is a new imaging device composed of PET and CT. ¹⁸F-Fluorodeoxyglucose (¹⁸F-FDG) is a commonly used tracer in the clinic. Cancer cells are more robust than other ordinary cells in that they can ingest glucose, and the structure of glucose is similar to the structure of ¹⁸F-FDG. Therefore, after the injection of ¹⁸F-FDG, ¹⁸F-FDG in tumor cells appears very thick during PET scanning. Therefore, PET/CT can determine the metabolic capacity and anatomical position of pancreatic tumor cells in the body accurately diagnose the patient's condition and tumor location. It plays a vital role in early diagnosis and accurate staging, predicts survival, and monitors therapeutic effectiveness and pancreatic cancer recurrence. Although ¹⁸F-FDG PET/CT has limitations in identifying inflammatory diseases and tumors, it still has good development potential. This article reviews the clinical application of ¹⁸F-FDG PET/CT in pancreatic cancer.

68Ga-FAPI-PET/CT improves diagnostic staging and radiotherapy planning of adenoid cystic carcinomas - Imaging analysis and histological validation

BACKGROUND

Adenoid cystic carcinomas (ACCs) are rare epithelial tumors mostly situated in the head and neck region and characterized by infiltrative growth. The tumor stroma of ACCs includes cancer-associated fibroblasts (CAFs) expressing Fibroblast Activation Protein (FAP), a new target for positron emission tomography (PET) imaging. Here we describe the value of PET/ computed tomography (PET/CT) imaging using ⁶⁸Ga-labelled FAP-Inhibitors (⁶⁸Ga-FAPI-PET/CT) and their clinical potential for staging and radiotherapy planning in 12 ACC patients (7 primary, 5 recurrent).

PATIENTS AND METHODS

Patients underwent contrast enhanced staging CT (ceCT) and magnetic resonance imaging (ceMRI) before ⁶⁸Ga-FAPI - PET/CT. PET-scans were acquired 10, 60 and 180 minutes after administration of 150-250 MBq of ⁶⁸Ga-labelled FAPI tracers. SUV_max and SUV_mean values of ACCs and healthy organs were obtained using a 60% of maximum iso-contour. FAP and alpha smooth muscle actin (α-SMA) immunohistochemistry was performed in 13 cases (3 with and 10 without ⁶⁸Ga FAPI-PET/CT). Staging and radiotherapy planning based on ⁶⁸Ga-FAPI-PET/CT versus ceCT/MRI alone were compared.

RESULTS

We observed elevated tracer uptake in all ACCs. Immunohistochemistry showed FAP-expressing CAFs in the tumor. Compared to conventional staging, ⁶⁸Ga-FAPI-PET/CT led to upstaging in 2/12 patients and to detection of additional metastases in 3 patients, thus in total 42% of patients had their staging altered. Moreover, ⁶⁸Ga-FAPI PET improved the accuracy of target volume delineation for radiotherapy, as compared to CT and MRI.

CONCLUSION

⁶⁸Ga-FAPI-PET/CT is a promising imaging modality for ACC, increasing the accuracy of staging exams and radiotherapy planning volumes, as compared conventional to CT and MRI.

The Role of Fibroblast Activation Protein Ligands in Oncologic PET Imaging

Fibroblast activation protein inhibitor emerges as a novel and highly promising agent for diagnostic and possibly theranostic application in various malignant and non-malignant diseases. FAPI impresses with its selective expression in several pathologies, ligand induced internalization, and presence in a large variety of malignancies. Current studies indicate that FAPI is equal or even superior to the current standard oncological tracer fluorodeoxyglucose in several oncological diseases. It seems to present lower background activity, stronger uptake in tumorous lesions and thus sharper contrasts. For improved comprehension of fibroblast activation, protein expression and clinicopathologic conditions, further studies are of essence.

Fully automated production of the fibroblast activation protein radiotracer [18 F]FAPI-74

We report herein an efficient and fully automated protocol for the radiosynthesis of [18 F]FAPI-74, a new positron emission tomography (PET) radiopharmaceutical for in vivo detection of the fibroblast activation protein. [18 F]FAPI-74 was synthesized via a rapid [18 F]aluminum fluoride coordination reaction, which was first developed on the flexible GE TRACERLab FX2N (FXN) platform and later translated to the cassette-based module Trasis AllInOne (AIO). The results obtained with both modules were comparable in terms of yield and reproducibility. Automation of [18 F]FAPI-74 radiosynthesis on the FXN was carried out in 35 min with a radiochemical yield (RCY) of 18.5 ± 2.5% (n = 5, relative to starting [18 F]fluoride). Method transfer to the AIO platform following minor optimizations allowed for the production of [18 F]FAPI-74 in an isolated RCY of 20 ± 2.5% [n = 3] with an overall synthesis time of 40 min. The radiochemical purity was greater than 95% for [18 F]FAPI-74, obtained from both modules. Overall, the protocol reliably provides a sterile and pyrogen-free good manufacturing practice (GMP) compliant product of [18 F]FAPI-74 suitable for clinical PET imaging.

Squaric Acid-Based Radiopharmaceuticals for Tumor Imaging and Therapy

Targeting vectors bound to a chelator represent a significant fraction of radiopharmaceuticals used nowadays for diagnostic and therapeutic purposes in nuclear medicine. The use of squaramides as coupling units for chelator and targeting vector helps to circumvent the disadvantages of several common coupling methods. This review gives an overview of the use of squaric acid diesters (SADE) as linking agents. It focuses on the conjugation of cyclic chelators, e.g., DOTA (1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid), as well as hybrid chelators like AAZTA⁵ (6-pentanoic acid-6-amino-1,4-diazepine tetracetic acid) or DATA^5m (6-pentanoic acid-6-amino-1,4-diazapine-triacetate) to different targeting vectors, e.g., prostate-specific membrane antigen inhibitors (KuE; PSMAi), fibroblast activation protein inhibitors (FAPi), and monoclonal antibodies (mAbs). An overview of the synthesis, radiolabeling, and in vitro and in vivo behavior of the described structures is given. The unique properties of SADE enable a fast and simple conjugation of chelators to biomolecules, peptides, and small molecules under mild conditions. Furthermore, SA-containing conjugates could not only display similar in vitro characteristics in terms of binding affinity when compared to reference compounds, but may even induce beneficial effects on the pharmacokinetic properties of these radiopharmaceuticals.

Clinical translational evaluation of Al18F-NOTA-FAPI for fibroblast activation protein-targeted tumour imaging

PURPOSE

In this study, a novel aluminium-[¹⁸F]fluoride (Al¹⁸F)-labelled 1,4,7‑triazacyclononane-N,N',N″-triacetic acid (NOTA)-conjugated fibroblast activation protein inhibitor (FAPI) probe, named Al¹⁸F-NOTA-FAPI, was developed for fibroblast activation protein (FAP)-targeted tumour imaging; it could deliver hundreds of millicuries of radioactivity using automated synthesis. The tumour detection efficacy of Al¹⁸F-NOTA-FAPI was further validated in both preclinical and clinical translational studies.

METHODS

The radiolabelling procedure of Al¹⁸F-NOTA-FAPI was optimized. Cell uptake and competitive binding assays were completed with the U87MG and A549 cell lines to evaluate the affinity and specificity of the Al¹⁸F-NOTA-FAPI probe. The biodistribution, pharmacokinetics, radiation dosimetry and tumour imaging efficacy of the Al¹⁸F-NOTA-FAPI probe were researched in healthy Kunming (KM) and/or U87MG model mice. After the approval of the ethical committee, the Al¹⁸F-NOTA-FAPI probe was translated into the clinic for PET/CT imaging of the first 10 cancer patients.

RESULTS

The radiolabelling yield of Al¹⁸F-NOTA-FAPI was 33.8 ± 3.2% using manual synthesis (n = 10), with a radiochemical purity over 99% and the specific activity of 9.3-55.5 MBq/nmol. The whole body effective dose of Al¹⁸F-NOTA-FAPI was estimated to be 1.24E - 02 mSv/MBq, which was lower than several other FAPI probes (⁶⁸Ga-FAPI-04, ⁶⁸Ga-FAPI-46 and ⁶⁸Ga-FAPI-74). In U87MG tumour-bearing mice, Al¹⁸F-NOTA-FAPI showed good tumour detection efficacy based on the results of micro PET/CT imaging and biodistribution studies. In an organ biodistribution study of patients, Al¹⁸F-NOTA-FAPI showed a lower SUVmean than 2-[¹⁸F]-fluoro-2-deoxy-D-glucose (2-[¹⁸F]FDG) in most organs, especially in the liver (1.1 ± 0.2 vs. 2.0 ± 0.9), brain (0.1 ± 0.0 vs. 5.9 ± 1.3), and bone marrow (0.9 ± 0.1 vs. 1.7 ± 0.4). Meanwhile, Al¹⁸F-NOTA-FAPI did not show extensive bone uptake, and was able to detect more lesions than 2-[¹⁸F]FDG in the PET/CT imaging of several patients.

CONCLUSION

The Al¹⁸F-NOTA-FAPI probe was successfully fabricated and applied in fibroblast activation protein-targeted tumour PET/CT imaging, which showed excellent imaging quality and tumour detection efficacy in U87MG tumour-bearing mice as well as in cancer patients.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2000038080. Registered 09 September 2020. http://www.chictr.org.cn/showproj.aspx?proj=61192.

Head-to-head intra-individual comparison of biodistribution and tumor uptake of 68Ga-FAPI and 18F-FDG PET/CT in cancer patients

PURPOSE

FAPI ligands (fibroblast activation protein inhibitor), a novel class of radiotracers for PET/CT imaging, demonstrated in previous studies rapid and high tumor uptake. The purpose of this study is the head-to-head intra-individual comparison of ⁶⁸Ga-FAPI versus standard-of-care ¹⁸F-FDG in PET/CT in organ biodistribution and tumor uptake in patients with various cancers.

MATERIAL AND METHODS

This international retrospective multicenter analysis included PET/CT data from 71 patients from 6 centers who underwent both ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT within a median time interval of 10 days (range 1-89 days). Volumes of interest (VOIs) were manually drawn in normal organs and tumor lesions to quantify tracer uptake by SUVmax and SUVmean. Furthermore, tumor-to-background ratios (TBR) were generated (SUVmax tumor/ SUVmax organ).

RESULTS

A total of 71 patients were studied of, which 28 were female and 43 male (median age 60). In 41 of 71 patients, the primary tumor was present. Forty-three of 71 patients exhibited 162 metastatic lesions. ⁶⁸Ga-FAPI uptake in primary tumors and metastases was comparable to ¹⁸F-FDG in most cases. The SUVmax was significantly lower for ⁶⁸Ga-FAPI than ¹⁸F-FDG in background tissues such as the brain, oral mucosa, myocardium, blood pool, liver, pancreas, and colon. Thus, ⁶⁸Ga-FAPI TBRs were significantly higher than ¹⁸F-FDG TBRs in some sites, including liver and bone metastases.

CONCLUSION

Quantitative tumor uptake is comparable between ⁶⁸Ga-FAPI and ¹⁸F-FDG, but lower background uptake in most normal organs results in equal or higher TBRs for ⁶⁸Ga-FAPI. Thus, ⁶⁸Ga-FAPI PET/CT may yield improved diagnostic information in various cancers and especially in tumor locations with high physiological ¹⁸F-FDG uptake.

Head-to-head intra-individual comparison of biodistribution and tumor uptake of 68Ga-FAPI and 18F-FDG PET/CT in cancer patients

Purpose

FAPI ligands (fibroblast activation protein inhibitor), a novel class of radiotracers for PET/CT imaging, demonstrated in previous studies rapid and high tumor uptake. The purpose of this study is the head-to-head intra-individual comparison of ⁶⁸Ga-FAPI versus standard-of-care ¹⁸F-FDG in PET/CT in organ biodistribution and tumor uptake in patients with various cancers.

Material and Methods

This international retrospective multicenter analysis included PET/CT data from 71 patients from 6 centers who underwent both ⁶⁸Ga-FAPI and ¹⁸F-FDG PET/CT within a median time interval of 10 days (range 1–89 days). Volumes of interest (VOIs) were manually drawn in normal organs and tumor lesions to quantify tracer uptake by SUVmax and SUVmean. Furthermore, tumor-to-background ratios (TBR) were generated (SUVmax tumor/ SUVmax organ).

Results

A total of 71 patients were studied of, which 28 were female and 43 male (median age 60). In 41 of 71 patients, the primary tumor was present. Forty-three of 71 patients exhibited 162 metastatic lesions. ⁶⁸Ga-FAPI uptake in primary tumors and metastases was comparable to ¹⁸F-FDG in most cases. The SUVmax was significantly lower for ⁶⁸Ga-FAPI than ¹⁸F-FDG in background tissues such as the brain, oral mucosa, myocardium, blood pool, liver, pancreas, and colon. Thus, ⁶⁸Ga-FAPI TBRs were significantly higher than ¹⁸F-FDG TBRs in some sites, including liver and bone metastases.

Conclusion

Quantitative tumor uptake is comparable between ⁶⁸Ga-FAPI and ¹⁸F-FDG, but lower background uptake in most normal organs results in equal or higher TBRs for ⁶⁸Ga-FAPI. Thus, ⁶⁸Ga-FAPI PET/CT may yield improved diagnostic information in various cancers and especially in tumor locations with high physiological ¹⁸F-FDG uptake.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05307-1.

Pancreatic Ductal Adenocarcinoma: The Dawn of the Era of Nuclear Medicine?

Pancreatic ductal adenocarcinoma (PDAC), accounting for 90-95% of all pancreatic tumors, is a highly devastating disease associated with poor prognosis. The lack of accurate diagnostic tests and failure of conventional therapies contribute to this pejorative issue. Over the last decade, the advent of theranostics in nuclear medicine has opened great opportunities for the diagnosis and treatment of several solid tumors. Several radiotracers dedicated to PDAC imaging or internal vectorized radiotherapy have been developed and some of them are currently under clinical consideration. The functional information provided by Positron Emission Tomography (PET) or Single Photon Emission Computed Tomography (SPECT) could indeed provide an additive diagnostic value and thus help in the selection of patients for targeted therapies. Moreover, the therapeutic potential of β-- and α-emitter-radiolabeled agents could also overcome the resistance to conventional therapies. This review summarizes the current knowledge concerning the recent developments in the nuclear medicine field for the management of PDAC patients.

In Vitro Evaluation of the Squaramide-Conjugated Fibroblast Activation Protein Inhibitor-Based Agents AAZTA5.SA.FAPi and DOTA.SA.FAPi

Recently, the first squaramide-(SA) containing FAP inhibitor-derived radiotracers were introduced. DATA^5m.SA.FAPi and DOTA.SA.FAPi with their non-radioactive complexes showed high affinity and selectivity for FAP. After a successful preclinical study with [⁶⁸Ga]Ga-DOTA.SA.FAPi, the first patient studies were realized for both compounds. Here, we present a new squaramide-containing compound targeting FAP, based on the AAZTA⁵ chelator 1,4-bis-(carboxylmethyl)-6-[bis-(carboxymethyl)-amino-6-pentanoic-acid]-perhydro-1,4-diazepine. For this molecule (AAZTA⁵.SA.FAPi), complexation with radionuclides such as gallium-68, scandium-44, and lutetium-177 was investigated, and the in vitro properties of the complexes were characterized and compared with those of DOTA.SA.FAPi. AAZTA⁵.SA.FAPi and its derivatives labelled with non-radioactive isotopes demonstrated similar excellent inhibitory potencies compared to the previously published SA.FAPi ligands, i.e., sub-nanomolar IC₅₀ values for FAP and high selectivity indices over the serine proteases PREP and DPPs. Labeling with all three radiometals was easier and faster with AAZTA⁵.SA.FAPi compared to the corresponding DOTA analogue at ambient temperature. Especially, scandium-44 labeling with the AAZTA derivative resulted in higher specific activities. Both DOTA.SA.FAPi and AAZTA⁵.SA.FAPi showed sufficiently high stability in different media. Therefore, these FAP inhibitor agents could be promising for theranostic approaches targeting FAP.

Stereo- and regiodefined DNA-encoded chemical libraries enable efficient tumour-targeting applications

The encoding of chemical compounds with amplifiable DNA tags facilitates the discovery of small-molecule ligands for proteins. To investigate the impact of stereo- and regiochemistry on ligand discovery, we synthesized a DNA-encoded library of 670,752 derivatives based on 2-azido-3-iodophenylpropionic acids. The library was selected against multiple proteins and yielded specific ligands. The selection fingerprints obtained for a set of protein targets of pharmaceutical relevance clearly showed the preferential enrichment of ortho-, meta- or para-regioisomers, which was experimentally verified by affinity measurements in the absence of DNA. The discovered ligands included novel selective enzyme inhibitors and binders to tumour-associated antigens, which enabled conditional chimeric antigen receptor T-cell activation and tumour targeting.

In Vivo Imaging of Fibroblast Activity Using a 68Ga-Labeled Fibroblast Activation Protein Alpha (FAP-α) Inhibitor: Study in a Mouse Rotator Cuff Repair Model

BACKGROUND

Rotator cuff repair site failure is a well-established clinical concern. Tendon-to-bone healing is initiated by inflammatory mediators followed by matrix synthesis by fibroblasts. The kinetics of fibroblast accumulation and activity are currently poorly understood.

METHODS

Ninety-six mice underwent supraspinatus tendon repair. Six were used for imaging using a novel 68Gallium (Ga)-labeled fibroblast activation protein alpha (FAP-α) inhibitor and positron emission tomography-computed tomography (PET/CT) at days 0 (before surgery), 3, 7, 14, and 28. Sixty-eight animals were divided into 4 groups to be evaluated at 3, 7, 14, or 28 days. Twenty-two native shoulders from mice without surgery were used as the control group (intact tendon). Six animals from each group were used for histological analysis; 6 from each group were used for evaluation of fibroblastic response-related gene expression; and 10 mice each from the intact, 14-day, and 28-day groups were used for biomechanical testing.

RESULTS

There was minimal localization of 68Ga-labeled FAP-α inhibitor in the shoulders at day 0 (before surgery). There was significantly increased uptake in the shoulders with surgery compared with the contralateral sides without surgery at 3, 7, and 14 days. 68Ga-labeled FAP-α inhibitor uptake in the surgically treated shoulders increased gradually and peaked at 14 days followed by a decrease at 28 days. Gene expression for smooth muscle alpha (α)-2 (acta2), FAP-α, and fibronectin increased postsurgery followed by a drop at 28 days. Immunohistochemical analysis showed that FAP-α-positive cell density followed a similar temporal trend, peaking at 14 days. All trends matched closely with the PET/CT results. Biomechanical testing demonstrated a gradual increase in failure load during the healing process.

CONCLUSIONS

68Ga-labeled FAP-α inhibitor PET/CT allows facile, high-contrast in vivo 3-dimensional imaging of fibroblastic activity in a mouse rotator cuff repair model.

CLINICAL RELEVANCE

Noninvasive imaging of activated fibroblasts using labeled radiotracers may be a valuable tool to follow the progression of healing at the bone-tendon interface.

Cancer-associated fibroblasts in non-small cell lung cancer: Recent advances and future perspectives

Non-small cell lung cancer (NSCLC) constitutes the majority of lung cancer, which is the leading cause of cancer-related deaths in the world. Nearly 70% of NSCLC patients were diagnosed at advanced stage with only 15% of five-year survival rate. Cancer-associated fibroblasts (CAFs) are the major component of tumor microenvironment and account for almost 70% of the cells in tumor tissues. By the crosstalk with cancer cells, CAFs reprogrammed cancer cell metabolism, remodeled extracellular matrix (ECM) and created a supportive niche for cancer stem cells. CAFs lead collective invasion of tumor cells and shape tumor immune microenvironment, promoting tumor metastasis and immune escape. In this review, we have summarized the progress of studies regarding CAFs influences on NSCLC in recent five years from the aspects of cell growth, metabolism, therapy resistance, invasion and metastasis and immune suppression. We have discussed the involved mechanisms and implications for the development of anti-NSCLC therapies. The current strategies of CAFs targeting and elimination have also been generalized. Only better understanding of the molecular biology of CAFs may contribute to the development of novel anti-NSCLC strategies.

Ligand engineering for theranostic applications

Targeted therapy of cancer is considered as promising alternative approach to conventional chemotherapy and radiotherapy. Recent advancements in biotechnology have significantly improved the identification of novel radiopharmaceuticals allowing for more accurate imaging and therapeutic targeting of epithelial tumors. The successful development of radiotracers critically depends on the selection and validation of the tumor-specific target structure, the technical approach employed for the identification of a target-specific ligand, and the evaluation and improvement of the binding properties and the pharmacokinetic profile of the ligand by biotechnological procedures or chemical modification, respectively. Employing rational design of a quinoline-based fibroblast activation protein inhibitor (FAPI) and 'high-through put' display technology using a sunflower trypsin inhibitor1-based peptide library, several FAPI derivatives and a novel αvβ6 integrin-binding peptide (SFITGv6) were identified. FAPI and SFITGv6 represent powerful radiopharmaceuticals for diagnostic imaging and/or endoradiotherapy of FAP- and αvβ6 integrin-expressing epithelial tumors, respectively.

Inflammatory Arthritis Induced by Anti-Programmed Death-1 Shown in 68Ga-FAPI PET/CT in a Patient With Esophageal Carcinoma

ABSTRACT

A 30-year-old woman with esophageal squamous cell carcinoma experienced joint pain and swelling in bilateral knees, wrists, and hand joints during the course of neoadjuvant immunochemotherapy. She underwent 18F-FDG and 68Ga-FAPI PET/CT for response assessment of the tumor and evaluating her arthritis. 68Ga-FAPI PET/CT detected intense uptake in multiple joints, consistent with her polyarthritis. However, these joints showed only mild FDG uptake. The tumor was in complete response, and her polyarthritis was considered as inflammatory arthritis induced by anti-PD1.

Theranostic Advances in Breast Cancer in Nuclear Medicine

The implication of 'theranostic' refers to targeting an identical receptor for diagnostic and therapeutic purposes, by the same radioligand, simultaneously or separately. In regard to extensive efforts, many considerable theranostic tracers have been developed in recent years. Emerging evidence strongly demonstrates the tendency of nuclear medicine towards therapies based on a diagnosis. This review is focused on the examples of targeted radiopharmaceuticals for the imaging and therapy of breast cancer.

Mars Shot for Nuclear Medicine, Molecular Imaging, and Molecularly Targeted Radiopharmaceutical Therapy

The Society of Nuclear Medicine and Molecular Imaging created the Value Initiative in 2017 as a major component of its strategic plan to further demonstrate the value of molecular imaging and molecularly targeted radiopharmaceutical therapy to patients, physicians, payers, and funding agencies. The research and discovery domain, 1 of 5 under the Value Initiative, has a goal of advancing the research and development of diagnostic and therapeutic nuclear medicine. Research and discovery efforts and achievements are essential to ensure a bright future for NM and to translate science to practice. Given the remarkable progress in the field, leaders from the research and discovery domain and society councils identified 5 broad areas of opportunity with potential for substantive growth and clinical impact. This article discusses these 5 growth areas, identifying specific areas of particularly high importance for future study and development. As there was an understanding that goals should be both visionary yet achievable, this effort was called the Mars shot for nuclear medicine.

In Vitro and In Situ Activity-Based Labeling of Fibroblast Activation Protein with UAMC1110-Derived Probes

Fibroblast activation protein (FAP) is a proline-selective protease that belongs to the S9 family of serine proteases. It is typically highly expressed in the tumor microenvironment (TME) and especially in cancer-associated fibroblasts, the main cell components of the tumor stroma. The exact role of its enzymatic activity in the TME remains largely unknown. Hence, tools that enable selective, activity-based visualization of FAP within the TME can help to unravel FAP’s function. We describe the synthesis, biochemical characterization, and application of three different activity-based probes (biotin-, Cy3-, and Cy5-labeled) based on the FAP-inhibitor UAMC1110, an in-house developed molecule considered to be the most potent and selective FAP inhibitor available. We demonstrate that the three probes have subnanomolar FAP affinity and pronounced selectivity with respect to the related S9 family members. Furthermore, we report that the fluorescent Cy3- and Cy5-labeled probes are capable of selectively detecting FAP in a cellular context, making these chemical probes highly suitable for further biological studies. Moreover, proof of concept is provided for in situ FAP activity staining in patient-derived cryosections of urothelial tumors.

Imaging of Fibroblast Activation Protein in Cancer Xenografts Using Novel (4-Quinolinoyl)-glycyl-2-cyanopyrrolidine-Based Small Molecules

Fibroblast activation protein (FAP) has become a favored target for imaging and therapy of malignancy. We have synthesized and characterized two new (4-quinolinoyl)-glycyl-2-cyanopyrrolidine-based small molecules for imaging of FAP, QCP01 and [111In]QCP02, using optical and single-photon computed tomography/CT, respectively. Binding of imaging agents to FAP was assessed in six human cancer cell lines of different cancer types: glioblastoma (U87), melanoma (SKMEL24), prostate (PC3), NSCLC (NCIH2228), colorectal carcinoma (HCT116), and lung squamous cell carcinoma (NCIH226). Mouse xenograft models were developed with FAP-positive U87 and FAP-negative PC3 cells to test pharmacokinetics and binding specificity in vivo. QCP01 and [111In]QCP02 demonstrated nanomolar inhibition of FAP at Ki values of 1.26 and 16.20 nM, respectively. Both were selective for FAP over DPP-IV, a related serine protease. Both enabled imaging of FAP-expressing tumors specifically in vivo. [111In]QCP02 showed high uptake at 18.2 percent injected dose per gram in the U87 tumor at 30 min post-administration.