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Telli T, Hosseini A, Settelmeier S, Kersting D, Kessler L, Weber WA, Rassaf T, Herrmann K, Varasteh Z. Imaging of Cardiac Fibrosis: How Far Have We Moved From Extracellular to Cellular? Semin Nucl Med 2024:S0001-2998(24)00025-4. [PMID: 38493001 DOI: 10.1053/j.semnuclmed.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 02/29/2024] [Indexed: 03/18/2024]
Abstract
Cardiovascular disease is the leading cause of morbidity and mortality worldwide. Myocardial fibrosis plays an important role in adverse outcomes such as heart failure and arrhythmias. As the pathological response and degree of scarring, and therefore clinical presentation varies from patient to patient, early detection of fibrosis is crucial for identifying the appropriate treatment approach and forecasting the progression of a disease along with the likelihood of disease-related mortality. Current imaging modalities provides information about either decreased function or extracellular signs of fibrosis. Targeting activated fibroblasts represents a burgeoning approach that could offer insights prior to observable functional alterations, presenting a promising focus for potential anti-fibrotic therapeutic interventions at cellular level. In this article, we provide an overview of imaging cardiac fibrosis and discuss the role of different advanced imaging modalities with the focus on novel non-invasive imaging of activated fibroblasts.
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Affiliation(s)
- Tugce Telli
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Atefeh Hosseini
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Stephan Settelmeier
- Westgerman Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
| | - David Kersting
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Lukas Kessler
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany; Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Wolfgang A Weber
- Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Tienush Rassaf
- Westgerman Heart- and Vascular Center, Department of Cardiology and Vascular Medicine, University Hospital Essen, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany
| | - Zohreh Varasteh
- Department of Nuclear Medicine, University Hospital Essen, Essen, Germany; Department of Nuclear Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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Su X, Zhao Y, Zhou X. Radiolabeled fibroblast activation protein inhibitors in the evaluation of myocardial fibrosis. Chin Med J (Engl) 2023; 136:2377-2379. [PMID: 37464383 PMCID: PMC10538885 DOI: 10.1097/cm9.0000000000002590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Indexed: 07/20/2023] Open
Affiliation(s)
- Xiangyu Su
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
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Cui Y, Wang Y, Wang S, Du B, Li X, Li Y. Highlighting Fibroblasts Activation in Fibrosis: The State-of-The-Art Fibroblast Activation Protein Inhibitor PET Imaging in Cardiovascular Diseases. J Clin Med 2023; 12:6033. [PMID: 37762974 PMCID: PMC10531835 DOI: 10.3390/jcm12186033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
Fibrosis is a common healing process that occurs during stress and injury in cardiovascular diseases. The evolution of fibrosis is associated with cardiovascular disease states and causes adverse effects. Fibroblast activation is responsible for the formation and progression of fibrosis. The incipient detection of activated fibroblasts is important for patient management and prognosis. Fibroblast activation protein (FAP), a membrane-bound serine protease, is almost specifically expressed in activated fibroblasts. The development of targeted FAP-inhibitor (FAPI) positron emission tomography (PET) imaging enabled the visualisation of FAP, that is, incipient fibrosis. Recently, research on FAPI PET imaging in cardiovascular diseases increased and is highly sought. Hence, we comprehensively reviewed the application of FAPI PET imaging in cardiovascular diseases based on the state-of-the-art published research. These studies provided some insights into the value of FAPI PET imaging in the early detection of cardiovascular fibrosis, risk stratification, response evaluation, and prediction of the evolution of left ventricular function. Future studies should be conducted with larger populations and multicentre patterns, especially for response evaluation and outcome prediction.
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Affiliation(s)
| | | | | | | | - Xuena Li
- Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang 110001, China; (Y.C.); (Y.W.); (S.W.); (B.D.)
| | - Yaming Li
- Department of Nuclear Medicine, The First Hospital of China Medical University, Shenyang 110001, China; (Y.C.); (Y.W.); (S.W.); (B.D.)
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Mayola MF, Thackeray JT. The Potential of Fibroblast Activation Protein-Targeted Imaging as a Biomarker of Cardiac Remodeling and Injury. Curr Cardiol Rep 2023; 25:515-523. [PMID: 37126137 DOI: 10.1007/s11886-023-01869-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 05/02/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease features adverse fibrotic processes within the myocardium, leading to contractile dysfunction. Activated cardiac fibroblasts play a pivotal role in the remodeling and progression of heart failure, but conventional diagnostics struggle to identify early changes in cardiac fibroblast dynamics. Emerging imaging methods visualize fibroblast activation protein (FAP) as a marker of activated fibroblasts, enabling non-invasive quantitative measurement of early cardiac remodeling. RECENT FINDINGS Retrospective analysis of oncology patient cohorts has identified cardiac uptake of FAP radioligands in response to various cardiovascular conditions. Small scale studies in dedicated cardiac populations have revealed FAP upregulation in injured myocardium, wherein the area of upregulation predicts subsequent ventricle dysfunction. Recent studies have demonstrated that silencing of FAP-expressing fibroblasts can reverse cardiac fibrosis in disease models. The parallel growth of FAP-targeted imaging and therapy provides the opportunity for imaging-based monitoring and refinement of treatments targeting cardiac fibroblast activation.
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Affiliation(s)
- Maday Fernandez Mayola
- Department of Nuclear Medicine, Hannover Medical School, Translational Cardiovascular Molecular Imaging, Carl Neuberg Str 1, 30625, Hannover, Germany
| | - James T Thackeray
- Department of Nuclear Medicine, Hannover Medical School, Translational Cardiovascular Molecular Imaging, Carl Neuberg Str 1, 30625, Hannover, Germany.
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Diekmann J, Bengel FM. Cardiac Applications of Fibroblast Activation Protein Imaging. PET Clin 2023:S1556-8598(23)00030-5. [PMID: 37117121 DOI: 10.1016/j.cpet.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Several promising applications of cardiac molecular fibroblast activation protein (FAP) imaging are emerging. Myocardial fibrosis plays a key role in the complex process of cardiac remodeling and can lead to adverse clinical outcomes such as left ventricular dysfunction, propensity to arrhythmias, and reduction of perfusion. If fibrosis becomes irreversible, patients can develop heart failure. Therefore identification and early fibrosis treatment is highly warranted. FAP-targeted imaging enables new insights into pathogenesis and treatment response in various cardiac diseases such as myocardial infarction, heart failure or systemic diseases being a new selective biomarker.
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Affiliation(s)
- Johanna Diekmann
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Street. 1, Hannover 30625, Germany.
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School, Carl-Neuberg-Street. 1, Hannover 30625, Germany
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Wang J, Huo L, Lin L, Niu N, Li X. In Vivo Fibroblast Activation of Systemic Sarcoidosis: A 68Ga-FAPI-04 PET/CT Imaging Study. Diagnostics (Basel) 2023; 13:diagnostics13081450. [PMID: 37189551 DOI: 10.3390/diagnostics13081450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/06/2023] [Accepted: 04/10/2023] [Indexed: 05/17/2023] Open
Abstract
A 47-year-old female with cardiac dysfunction and lymphadenopathy underwent 18FDG PET/CT and 68Ga-FAPI-04 imaging for tumor screening. Mild uptake in the left ventricular wall was detected on the oncology 18FDG PET/CT. True myocardiac-involvement could not be distinguished with physiological uptake. The following 68Ga-FAPI-04 showed intense heterogeneous uptake in the left ventricular wall, particularly in the septum and apex area, corresponding with the late gadolinium enhancement regions shown by cardiac MR. Intense uptake was also noted in the mediastinal and bilateral hilar lymph nodes. Endomyocardial biopsy demonstrated sarcoidosis.
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Affiliation(s)
- Jingnan Wang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing 100730, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing 100730, China
| | - Lu Lin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Na Niu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing 100730, China
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, 1010 Vienna, Austria
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Barton AK, Tzolos E, Bing R, Singh T, Weber W, Schwaiger M, Varasteh Z, Slart RHJA, Newby DE, Dweck MR. Emerging molecular imaging targets and tools for myocardial fibrosis detection. Eur Heart J Cardiovasc Imaging 2023; 24:261-275. [PMID: 36575058 PMCID: PMC9936837 DOI: 10.1093/ehjci/jeac242] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 11/20/2022] [Indexed: 12/29/2022] Open
Abstract
Myocardial fibrosis is the heart's common healing response to injury. While initially seeking to optimize the strength of diseased tissue, fibrosis can become maladaptive, producing stiff poorly functioning and pro-arrhythmic myocardium. Different patterns of fibrosis are associated with different myocardial disease states, but the presence and quantity of fibrosis largely confer adverse prognosis. Current imaging techniques can assess the extent and pattern of myocardial scarring, but lack specificity and detect the presence of established fibrosis when the window to modify this process may have ended. For the first time, novel molecular imaging methods, including gallium-68 (68Ga)-fibroblast activation protein inhibitor positron emission tomography (68Ga-FAPI PET), may permit highly specific imaging of fibrosis activity. These approaches may facilitate earlier fibrosis detection, differentiation of active vs. end-stage disease, and assessment of both disease progression and treatment-response thereby improving patient care and clinical outcomes.
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Affiliation(s)
- Anna K Barton
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Evangelos Tzolos
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Rong Bing
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Trisha Singh
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Wolfgang Weber
- Department of Nuclear Medicine, Clinikum rechts der Isar, Technical University of Munich, Ismaniger Straße 22, 81675 Munich, Germany
| | - Markus Schwaiger
- Department of Nuclear Medicine, Clinikum rechts der Isar, Technical University of Munich, Ismaniger Straße 22, 81675 Munich, Germany
| | - Zohreh Varasteh
- Department of Nuclear Medicine, Clinikum rechts der Isar, Technical University of Munich, Ismaniger Straße 22, 81675 Munich, Germany
| | - Riemer H J A Slart
- Faculty of Medical Sciences, University of Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, The Netherlands
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Little France Crescent, Edinburgh EH16 4SB, UK
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Wang G, Yang Q, Wu S, Xu X, Li X, Liang S, Pan G, Zuo C, Zhao X, Cheng C, Liu S. Molecular imaging of fibroblast activity in pressure overload heart failure using [ 68 Ga]Ga-FAPI-04 PET/CT. Eur J Nucl Med Mol Imaging 2023; 50:465-474. [PMID: 36171409 DOI: 10.1007/s00259-022-05984-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 09/20/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE We aimed to evaluate whether [68 Ga]Ga-FAPI-04 PET/CT could characterize the early stages of cardiac fibrosis in pressure overload heart failure. METHODS Sprague-Dawley rats underwent abdominal aortic constriction (AAC) (n = 12) and sham surgery (n = 10). All rats were scanned with [68 Ga]Ga-FAPI-04 PET/CT at 2, 4, and 8 weeks after surgery. The expression of fibroblast activation protein (FAP) in the myocardium was detected by immunohistochemistry. [68 Ga]Ga-FAPI-04 PET signal and FAP expression were compared between two groups. RESULTS Compared with the sham group, the AAC group presented with decreased ejection fraction (EF) and fractional shortening (FS) and increased left ventricular internal dimensions in diastole (LVIDd) and systole (LVIDs) at 4 and 8 weeks (all p < 0.01). The AAC group showed higher [68 Ga]Ga-FAPI-04 accumulation in the heart than the sham group at 2, 4, and 8 weeks, and FAPI increased significantly from 2 to 8 weeks (all p < 0.001). Immunohistochemistry confirmed the higher density of the FAP+ area in the AAC group. The intensity of the [68 Ga]Ga-FAPI-04 correlated with the density of the FAP+ area (p < 0.001). The expression of the [68 Ga]Ga-FAPI-04 at 4 weeks correlated with the deterioration of cardiac function at 8 weeks (EF: R = - 0.87; FS: R = - 0.72; LVIDd: R = 0.77; LVIDs: R = 0.79; all p < 0.001). The AAC group also showed an increased [68 Ga]Ga-FAPI-04 signal in the liver, peaking at 4 weeks and then declining. Cardiac and liver PET signals correlated at 4 weeks in the AAC group (R = 0.69, p = 0.0010), suggesting an early fibrotic link between organs. A combination of the [68 Ga]Ga-FAPI-04 intensity in the heart and liver at 4 weeks better predicted the deterioration of cardiac function at 8 weeks. CONCLUSIONS The activated fibroblasts in the heart and liver after pressure overload can be monitored by [68 Ga]Ga-FAPI-04 PET/CT, which reveals an early fibrotic link in cardio-liver interactions and could better predict nonischemic heart failure prognosis.
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Affiliation(s)
- Guokun Wang
- Department of Cardiovascular Surgery, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, Shanghai, China
| | - Qinqin Yang
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Shengyong Wu
- Department of Military Health Statistics, Naval Medical University, Shanghai, China
| | - Xudong Xu
- Department of Cardiology, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xiao Li
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Siyu Liang
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Guixia Pan
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Changjing Zuo
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Xianxian Zhao
- Department of Cardiology, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China
| | - Chao Cheng
- Department of Nuclear Medicine, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
| | - Suxuan Liu
- Department of Cardiology, the First Affiliated Hospital (Changhai Hospital) of Naval Medical University, 168 Changhai Road, Shanghai, 200433, China.
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Lyu Z, Han W, Zhao H, Jiao Y, Xu P, Wang Y, Shen Q, Yang S, Zhao C, Tian L, Fu P. A clinical study on relationship between visualization of cardiac fibroblast activation protein activity by Al18F-NOTA-FAPI-04 positron emission tomography and cardiovascular disease. Front Cardiovasc Med 2022; 9:921724. [PMID: 36072860 PMCID: PMC9441604 DOI: 10.3389/fcvm.2022.921724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Accepted: 08/03/2022] [Indexed: 11/13/2022] Open
Abstract
Objective FAP plays a vital role in myocardial injury and fibrosis. Although initially used to study imaging of primary and metastatic tumors, the use of FAPI tracers has recently been studied in cardiac remodeling after myocardial infarction. The study aimed to investigate the application of FAPI PET/CT imaging in human myocardial fibrosis and its relationship with clinical factors. Materials and methods Retrospective analysis of FAPI PET/CT scans of twenty-one oncological patients from 05/2021 to 03/2022 with visual uptake of FAPI in the myocardium were applying the American Heart Association 17-segment model of the left ventricle. The patients’ general data, echocardiography, and laboratory examination results were collected, and the correlation between PET imaging data and the above data was analyzed. Linear regression models, Kendall’s TaU-B test, the Spearman test, and the Mann–Whitney U test were used for the statistical analysis. Results 21 patients (60.1 ± 9.4 years; 17 men) were evaluated with an overall mean LVEF of 59.3 ± 5.4%. The calcific plaque burden of LAD, LCX, and RCA are 14 (66.7%), 12 (57.1%), and 9 (42.9%). High left ventricular SUVmax correlated with BMI (P < 0.05) and blood glucose level (P < 0.05), and TBR correlated with age (P < 0.05). A strong correlation was demonstrated between SUVmean and CTnImax (r = 0.711, P < 0.01). Negative correlation of SUVmean and LVEF (r = −0.61, P < 0.01), SUVmax and LVEF (r = −0.65, P < 0.01) were found. ROC curve for predicting calcified plaques by myocardial FAPI uptake (SUVmean) in LAD, LCX, and RCA territory showed AUCs were 0.786, 0.759, and 0.769. Conclusion FAPI PET/CT scans might be used as a new potential method to evaluate cardiac fibrosis to help patients’ management further. FAPI PET imaging can reflect the process of myocardial fibrosis. High FAPI uptakes correlate with cardiovascular risk factors and the distribution of coronary plaques.
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Affiliation(s)
- Zhehao Lyu
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wei Han
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongyue Zhao
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuying Jiao
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Peng Xu
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yangyang Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qiuyi Shen
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Shuai Yang
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Changjiu Zhao
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lin Tian
- Department of Pathology, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- Lin Tian,
| | - Peng Fu
- Department of Nuclear Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin, China
- *Correspondence: Peng Fu,
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Clinical summary of fibroblast activation protein inhibitor-based radiopharmaceuticals: cancer and beyond. Eur J Nucl Med Mol Imaging 2022; 49:2844-2868. [DOI: 10.1007/s00259-022-05706-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/23/2022] [Indexed: 02/06/2023]
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