Haniye Elahifard, Mohammad Hadi Samadi, Alireza Bari, Ehsan Soltani, Hassan Kamali, Atena Aghaee
A 66-year-old man with inoperable malignant scalp melanoma, refractory to immunotherapy, underwent 99mTc-HYNIC-TOC SPECT/CT for evaluating the possibility of radioligand therapy with 177Lu-DOTATATE, which demonstrated no tracer uptake in scalp lesions, precluding 177Lu-DOTATATE therapy. Subsequent disease progression prompted 99mTc-FAPI-46 SPECT/CT, which showed intense tracer uptake in lesions and prompted radioligand therapy with 177Lu-FAPI-2286. After 4 cycles of treatment, all lesions showed regression and he was referred for tumor resection. This case illustrates the clinical utility of FAPI-based theranostic and shows 99mTc-FAPI SPECT/CT can directly inform targeted radioligand therapy using 177Lu-FAPI, thereby expanding therapeutic options in melanoma management.