Significance Cancers, fibroses, and inflammatory disorders are characterized by increased deposition of the extracellular matrix (ECM). ECM biomarkers that are selectively expressed at these disease sites are attractive targets for imaging and therapeutic approaches. Nanobodies against these biomarkers would be pertinent vehicles for the accumulation of imaging and therapeutic cargo at disease sites, potentially increasing specificity and reducing background. We demonstrate the specificity of one such anti-ECM nanobody by using immuno-PET/CT and show that it detects multiple models of cancer, including early lesions and metastases, and also fibroses, with excellent specificity and clarity. Thus, novel strategies for delivering imaging and therapeutic probes specifically to the ECM in disease sites may prove particularly valuable for detection and treatment of cancer in patients.