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A Curious "Mickey Mouse" Sign: Physiological FAPI Uptake in Uterus Didelphys on 68Ga-FAPI PET/CT.

Sharjeel Usmani¹, Khulood Al Riyami, Aisha Ismaila

¹Department of Radiology and Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC), University Medical City, Muscat, Oman.

Clinical Nuclear Medicine

|June 24, 2026

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A 42-year-old woman

Area of Science:

Oncologic imaging
Nuclear medicine
Radiopharmaceuticals

Background:

68Ga-FAPI PET/CT is an emerging imaging modality for cancer staging.
Fibroblast activation protein (FAPI) is a target in cancer imaging.
Congenital Müllerian anomalies can present incidentally in imaging studies.

Purpose of the Study:

To report an incidental finding of uterus didelphys during cancer staging.
To describe the characteristic imaging appearance of uterus didelphys on 68Ga-FAPI PET/CT.
To highlight the importance of recognizing physiological FAPI uptake patterns.

Main Methods:

A patient with invasive lobular carcinoma underwent staging with 68Ga-FAPI PET/CT.
Incidental pelvic findings were evaluated with fused PET/CT.

Keywords:

FAPI PET/CT cancer-associated fibroblasts fibroblast activation protein lobular breast cancer

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Subsequent ultrasonography was performed for confirmation.

Main Results:

68Ga-FAPI PET/CT showed primary breast cancer and nodal metastases.
Symmetric intense pelvic tracer uptake was observed, corresponding to uterus didelphys.
The "Mickey Mouse" sign on PET indicated physiological FAPI accumulation in duplicated uterine horns.

Conclusions:

Uterus didelphys can present as a "Mickey Mouse" sign on 68Ga-FAPI PET/CT.
Physiological FAPI uptake in Müllerian anomalies can mimic metastatic disease.
Radiologists must be aware of these physiological patterns to avoid misdiagnosis.