Fibroblast Activation Protein Inhibitor Theranostics in Sarcoma: Current Evidence and Future Directions

Sarcomas are rare and heterogeneous cancers arising from mesenchymal tissues, presenting diagnostic and therapeutic challenges. Fibroblast activation protein (FAP), overexpressed in the tumor microenvironment of many sarcomas, has emerged as a promising theranostic target. FAP inhibitors (FAPI)-PET/CT demonstrates excellent sensitivity and specificity in detecting primary tumors, local recurrence, and distant metastases, even in low-grade sarcomas. This facilitates accurate staging and personalized treatment. Various FAPI radiotracers, including FAPI-04, FAPI-46, and FAP-2286, offer unique pharmacokinetic properties. FAPI-targeted radionuclide therapy (TRT) employs therapeutic radioisotopes to deliver targeted radiation to FAP-expressing tumor cells. Early clinical trials show promising disease control rates and manageable toxicity profiles. However, challenges remain, including FAP expression heterogeneity and the need for optimized treatment protocols. The aim of this review is to provide a comprehensive overview of the current evidence and future directions of FAPI-based theranostics in sarcoma management, highlighting its potential to improve patient outcomes.