[68Ga]Ga-FAPI-04 PET/CT in a patient with endometriosis: a potential game changer?
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The paper reports a single case of a 43-year-old woman with known endometriosis presenting with dysmenorrhea, dyschezia, and hematochezia, after hysterectomy had previously shown infiltrative bowel endometriosis. After MRI confirmed bowel involvement with a circumscribed lesion infiltrating the sigmoid colon, the patient underwent preoperative [68Ga]Ga-FAPI-04 PET/CT 10 minutes after injection of 148 MBq, which showed intense tracer uptake at the MRI-confirmed sigmoid lesion (SUVmax 9.8) and also detected additional suspected endometriotic sites in the left ovary and ligamentum teres uteri bilaterally that were not seen on MRI. Histopathology after a second surgery confirmed deep infiltrating endometriosis extragenitalis, and the authors note the main limitation that evidence is based on a single confirmed case. This paper is centrally about endometriosis — it uses [68Ga]Ga-FAPI-04 PET/CT to demonstrate intense detection of deep infiltrating endometriosis and additional lesions beyond MRI.
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Abstract
A 43-year-old woman with a known history of endometriosis presented with dysmenorrhea, dyschezia, and hematochezia. She had previously undergone a hysterectomy, during which infiltrative endometriosis in the bowel was identified. To guide further treatment decisions, a magnet resonance imaging (MRI) was performed, confirming bowel involvement and revealing a circumscribed lesion infiltrating the sigmoid colon. Due to persistent symptoms, the patient opted for surgery. For preoperative planning, a fibroblast activation protein inhibitor (FAPI) positron emission tomography/ computed tomography with [68Ga]Ga-FAPI-04 was conducted. PET images, acquired 10 min after administration 148 MBq of [68Ga]Ga-FAPI-04, showed intense tracer uptake (Fig. A; left column: maximum intensity projection; right column: axial slices of PET/CT fusion and PET; big arrow head: endometriosis in the sigmoid colon, SUVmax 9.8) at the same location as the MRI finding (Fig. B, axial and sagittal slices of contrast enhanced T1-weighted fat saturated sequence), thus confirming the MRI result. Additionally, the PET scan revealed intense uptake in the left ovary and the ligamentum teres uteri bilaterally (Fig. A, small arrowheads; SUVmax: 11.3, 7.3 and 5.4, respectively) suggesting the presence of additional endometriotic lesions undetected by MRI. The patient underwent a second surgical procedure, which histopathologically confirmed a deep infiltrating endometriosis extragenitalis. Endometriosis, characterized by the ectopic growth of endometrial-like tissue, is a common gynecological disease affecting approximately 10% of reproductive-age women [1]. It can cause significant symptoms, including dysmenorrhea, dyspareunia, infertility, and gastrointestinal disturbances [2]. In addition to its physical effects, endometriosis can also affect mental health [3]. Thus, endometriosis significantly impact the quality of life of patients [4]. Diagnosis is primarily symptom-based, which can be challenging due to their variety and the heterogenic phenotype of endometriosis overlapping with other diseases. A definitive diagnosis is mostly confirmed through diagnostic laparoscopy. While transvaginal ultrasound is the first-line imaging modality, MRI is often used as a second-line tool for assessing disease extent and aiding in surgical planning [5]. This case highlights the potential role of 68Ga-FAPI PET/CT in detecting endometriotic lesions. Not only did the scan confirm the known lesion, but also identified additional sites of involvement undetected by MRI. Many studies have demonstrated the biodistribution of the 68Ga-labeled FAPI tracer, often showing intense uptake in the uterus [6,7,8]. There has been a previous case report showing only faint uptake in one endometriotic lesion [9]. To the best of our knowledge, this is the first confirmed case of endometriosis demonstrated on 68Ga-FAPI PET/CT with clear and intensive uptake. Therefore, 68Ga-FAPI PET/CT could represent a promising diagnostic modality for endometriosis, alongside many malignant diseases in which it has proven effective [10,11,12,13]. Our observation is supported by a recent preclinical study that found FAP expression in the immune microenvironment of endometriosis from various locations [14]. This case may provide a rationale for future studies systematically analyzing FAP expression in endometriosis across larger patient cohorts, investigating the value of 68Ga-FAPI PET/CT. A prospective study was recently initiated and is currently underway investigating this issue (NCT06792318).
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doi:10.22028/D291-46446
| Title: | [68Ga]Ga-FAPI-04 PET/CT in a patient with endometriosis: a potential game changer? |
| Author(s): | Burgard, Caroline Rosar, Florian Ezziddin, Samer Hamoud, Bashar H. Solomayer, Erich-Franz Laschke, Matthias W. Constantin, Alin Bartholomä, Mark |
| Language: | English |
| Title: | European Journal of Nuclear Medicine and Molecular Imaging |
| Volume: | 52 |
| Issue: | 12 |
| Pages: | 4350-4351 |
| Publisher/Platform: | Springer Nature |
| Year of Publication: | 2025 |
| DDC notations: | 610 Medicine and health |
| Publikation type: | Journal Article |
| Abstract: | A 43-year-old woman with a known history of endometriosis presented with dysmenorrhea, dyschezia, and hematochezia. She had previously undergone a hysterectomy, during which infiltrative endometriosis in the bowel was identified. To guide further treatment decisions, a magnet resonance imaging (MRI) was performed, confirming bowel involvement and revealing a circumscribed lesion infiltrating the sigmoid colon. Due to persistent symptoms, the patient opted for surgery. For preoperative planning, a fibroblast activation protein inhibitor (FAPI) positron emission tomography/ computed tomography with [68Ga]Ga-FAPI-04 was conducted. PET images, acquired 10 min after administration 148 MBq of [68Ga]Ga-FAPI-04, showed intense tracer uptake (Fig. A; left column: maximum intensity projection; right column: axial slices of PET/CT fusion and PET; big arrow head: endometriosis in the sigmoid colon, SUVmax 9.8) at the same location as the MRI finding (Fig. B, axial and sagittal slices of contrast enhanced T1-weighted fat saturated sequence), thus confirming the MRI result. Additionally, the PET scan revealed intense uptake in the left ovary and the ligamentum teres uteri bilaterally (Fig. A, small arrowheads; SUVmax: 11.3, 7.3 and 5.4, respectively) suggesting the presence of additional endometriotic lesions undetected by MRI. The patient underwent a second surgical procedure, which histopathologically confirmed a deep infiltrating endometriosis extragenitalis. Endometriosis, characterized by the ectopic growth of endometrial-like tissue, is a common gynecological disease affecting approximately 10% of reproductive-age women [1]. It can cause significant symptoms, including dysmenorrhea, dyspareunia, infertility, and gastrointestinal disturbances [2]. In addition to its physical effects, endometriosis can also affect mental health [3]. Thus, endometriosis significantly impact the quality of life of patients [4]. Diagnosis is primarily symptom-based, which can be challenging due to their variety and the heterogenic phenotype of endometriosis overlapping with other diseases. A definitive diagnosis is mostly confirmed through diagnostic laparoscopy. While transvaginal ultrasound is the first-line imaging modality, MRI is often used as a second-line tool for assessing disease extent and aiding in surgical planning [5]. This case highlights the potential role of 68Ga-FAPI PET/CT in detecting endometriotic lesions. Not only did the scan confirm the known lesion, but also identified additional sites of involvement undetected by MRI. Many studies have demonstrated the biodistribution of the 68Ga-labeled FAPI tracer, often showing intense uptake in the uterus [6,7,8]. There has been a previous case report showing only faint uptake in one endometriotic lesion [9]. To the best of our knowledge, this is the first confirmed case of endometriosis demonstrated on 68Ga-FAPI PET/CT with clear and intensive uptake. Therefore, 68Ga-FAPI PET/CT could represent a promising diagnostic modality for endometriosis, alongside many malignant diseases in which it has proven effective [10,11,12,13]. Our observation is supported by a recent preclinical study that found FAP expression in the immune microenvironment of endometriosis from various locations [14]. This case may provide a rationale for future studies systematically analyzing FAP expression in endometriosis across larger patient cohorts, investigating the value of 68Ga-FAPI PET/CT. A prospective study was recently initiated and is currently underway investigating this issue (NCT06792318). |
| DOI of the first publication: | 10.1007/s00259-025-07252-9 |
| URL of the first publication: | https://link.springer.com/article/10.1007/s00259-025-07252-9 |
| Link to this record: | urn:nbn:de:bsz:291--ds-464463 hdl:20.500.11880/40726 http://dx.doi.org/10.22028/D291-46446 |
| ISSN: | 1619-7089 1619-7070 |
| Date of registration: | 23-Oct-2025 |
| Faculty: | M - Medizinische Fakultät |
| Department: | M - Chirurgie M - Frauenheilkunde M - Radiologie |
| Professorship: | M - Prof. Dr. Samer Ezziddin M - Prof. Dr. Michael D. Menger M - Prof. Dr. E.-F. Solomayer |
| Collections: | SciDok - Der Wissenschaftsserver der Universität des Saarlandes |
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