# FAP imaging to stop futile pancreatic surgery

Source: https://nuclide.cc/opportunities/opp-fap-pancreatic-staging/  
Nuclide record `opp-fap-pancreatic-staging` (Opportunity). Data CC BY-NC 4.0, attribute "Data from Nuclide (nuclide.cc)"; commercial use needs a licence.

## TL;DR

Four in ten pancreatic cancer patients whose scans say the tumour can be removed turn out, once opened up, to have disease that cannot be removed. A scan that lights up the scar tissue around tumour deposits sees more of that hidden disease than the standard one.

## Summary

The number that defines this opportunity comes from a Cochrane review: the median pre-test probability of unresectable disease after CT was 41.4%, meaning 41 of 100 participants whose cancer looked resectable on CT were found unresectable at laparotomy. The operation that follows is major surgery with no curative benefit.

FAP imaging attacks that gap directly, because pancreatic ductal adenocarcinoma is a stroma-rich tumour and the tracer reports the fibroblast compartment rather than glucose uptake. A 62-patient prospective study of 18F-FAPI-04 against FDG upgraded the TNM stage in 14 patients, with higher uptake in primary tumours, nodes, liver and peritoneal deposits, and FDG missed one patient with cancer that FAPI found. A PDAC-specific meta-analysis of 7 studies and 322 patients gives pooled sensitivity of 0.99 against 0.84 for FDG with comparable specificity. A 20-patient Korean study found FAPI-74 detected metastatic nodes in 50% of cases against 0% for FDG.

The gap in the evidence is precise and worth stating: no trial has yet reported that FAPI-based selection reduces the non-curative laparotomy rate. The completed SOFIE phase 2 (NCT05262855, 63 patients) measured sensitivity against histopathology, not operations avoided. On the therapy side the picture is discouraging — FRONTIER was terminated early for rapid clearance and low tumour doses, and across eight compassionate-use patients the predominant outcome was radiological progression — which strengthens the case for treating this as a diagnostic opportunity rather than a theranostic one.

## Fields

- Kind: Opportunity
- Last checked: 2026-09-23
- Also known as: FAPI PET in PDAC
- Tags: unmet need first; pancreas; surgical selection; stroma

## Sources

- Cochrane review: unresectable disease found at laparotomy after CT: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.cd009323.pub3/full
- 18F-FAPI-04 against FDG in 62 patients, J Nucl Med 2024: https://jnm.snmjournals.org/content/jnumed/65/2/206.full.pdf
- NCT05262855: [68Ga]FAPI-46 phase 2 in pancreatic cancer: https://clinicaltrials.gov/study/NCT05262855
- [18F]AlF-FAPI-74 in potentially resectable pancreatic cancer: https://pmc.ncbi.nlm.nih.gov/articles/PMC11634952/
- FRONTIER terminated early for rapid clearance: https://pmc.ncbi.nlm.nih.gov/articles/PMC12607575/

## Connected records

- isotopes: [Fluorine-18](https://nuclide.cc/isotopes/f-18/), [Gallium-68](https://nuclide.cc/isotopes/ga-68/), [Lutetium-177](https://nuclide.cc/isotopes/lu-177/)
- indications: [Pancreatic ductal adenocarcinoma](https://nuclide.cc/indications/pancreatic-cancer/)
- technologies: [FAPI PET](https://nuclide.cc/technologies/fapi-pet/), [FDG PET](https://nuclide.cc/technologies/fdg-pet/), [PET/CT](https://nuclide.cc/technologies/pet-ct/)
- targets: [FAP](https://nuclide.cc/targets/fap/)
- drugs: [FAP-2286 (177Lu / 68Ga)](https://nuclide.cc/drugs/fap-2286/), [Gallium-68 FAPI-46](https://nuclide.cc/drugs/ga-68-fapi-46/)

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