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During the last decade, PSMA-PET/CT became a mainstay in the imaging of prostate cancer. However, PSMA is also expressed in the neo-vasculature of various non-prostatic tumors [1]. Amongst other somatostatin receptor-targeted tracers, DOTATOC-PET/CT is the current gold standard for imaging of well-differentiated neuroendocrine tumors arising in the gastrointestinal tract [2].
This image presents a patient who was originally diagnosed with a high-grade prostate carcinoma (Gleason score 9, initial PSA 48 ng/ml). Consequently, an atypically located liver lesion was histologically proven to be a well-differentiated neuroendocrine tumor (G2). Due to his transplant kidney, the patient was not allowed to receive contrast media; hence, he received staging with [18F]F-PSMA-1007 and [68 Ga]Ga-DOTATOC PET/CT.
In the PSMA-PET, the uptake of the prostate carcinoma was SUVmax 55.5 and the suspected liver metastasis was SUVmax 106.2; no uptake was seen in the neuroendocrine primary tumor and only faint uptake (SUVmax 8.5) in a peritoneal lymph node. In the DOTATOC-PET, the uptake of the duodenal neuroendocrine primary tumor was SUVmax 67.9, the positive lymph node in the related drainage was SUVmax 91.2, and the liver metastasis was SUVmax 221.3; the adenocarcinoma of the prostate was somatostatin-receptor negative.
The presented image contains two interesting points. First, it demonstrates the high variability of PSMA expression in non-prostatic tumor lesions and its dependency of the local tumor microenvironment (e.g., site of metastasis, neoangiogenetic activity, organ-specific perfusion effects). Second, it serves as a reminder that an uncritical belief in strong biological signals obtained with highly specific tracers can lead to an overestimate of the “histo-radiological” performance of molecular imaging. A clinically uncommon situation—such as suspicion of liver metastatic prostate cancer without additional lymph node or bone metastases—still needs histopathological validation!
Data Availability
The data that support the findings of this study are available from the corresponding author, EW, upon reasonable request.
References
Salas Fragomeni RA, Amir T, Sheikhbahaei S, et al. Imaging of nonprostate cancers using PSMA-targeted radiotracers: rationale, current state of the field, and a call to arms. J Nucl Med. 2018;59(6):871–7. https://doi.org/10.2967/jnumed.117.203570.
Bozkurt MF, Virgolini I, Balogova S, Beheshti M, et al. Guideline for PET/CT imaging of neuroendocrine neoplasms with 68Ga-DOTA-conjugated somatostatin receptor targeting peptides and 18F-DOPA. Eur J Nucl Med Mol Imaging. 2017;44:1588–601. https://doi.org/10.1007/s00259-017-3728-y.
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Winter, E., Zschäbitz, S. & Kratochwil, C. Liver metastasis of a neuroendocrine tumor demonstrates intense uptake in PSMA-PET—but not its lymph-node metastasis and primary-tumor. Eur J Nucl Med Mol Imaging 50, 2226–2227 (2023). https://doi.org/10.1007/s00259-023-06120-8
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DOI: https://doi.org/10.1007/s00259-023-06120-8