We present a 54-year-old man with hepatocellular carcinoma (HCC) presenting with diffuse bone pain 6 months postradiofrequency ablation. ^99m Tc-FAPI-46 SPECT/CT was performed to evaluate disease extent, confirming locally active primary HCC and revealing widespread FAPI-avid bone metastases. Considering the low performance of FDG PET/CT scan in hepatocellular carcinoma, this case highlights ^99m Tc- FAPI-46 Scintigraphy as a highly sensitive, accessible radiopharmaceutical for comprehensive HCC restaging, offering excellent visualization of stroma-rich extrahepatic lesions and critical insights into advanced tumor biology.

A 66-year-old man with inoperable malignant scalp melanoma, refractory to immunotherapy, underwent ^99m Tc-HYNIC-TOC SPECT/CT for evaluating the possibility of radioligand therapy with ¹⁷⁷ Lu-DOTATATE, which demonstrated no tracer uptake in scalp lesions, precluding ¹⁷⁷ Lu-DOTATATE therapy. Subsequent disease progression prompted ^99m Tc-FAPI-46 SPECT/CT, which showed intense tracer uptake in lesions and prompted radioligand therapy with ¹⁷⁷ Lu-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 ^99m Tc-FAPI SPECT/CT can directly inform targeted radioligand therapy using ¹⁷⁷ Lu-FAPI, thereby expanding therapeutic options in melanoma management.