Late ⁶⁸Ga PSMA-positive Pancreatic Metastasis From Renal Cell Carcinoma in a Patient with Metastatic Prostate Cancer: A Mission Impossible

We present the case of a patient with newly diagnosed high-risk prostate cancer.The patient underwent nephrectomy for renal cell carcinoma (RCC) in 2009.The prostate-specific membrane antigen (PSMA) scan revealed a primary tumor with seminal vessel involvement, PSMA-positive regional lymph nodes, several nodular lung lesions with mild PSMA uptake, PSMA-positive mediastinal lymph nodes, and a PSMA-positive mass in the pancreatic head.Ultrasound-guided biopsy was performed for the pancreatic lesions revealing metastasis from a RCC.Simultaneous treatment for prostate cancer and metastatic RCC was initiated.To separate metastatic sites for both primaries, we attempted to use fluorodeoxyglucose positron emission tomography/computed tomography, which was moderately positive for the pancreatic mass but not for the other locations.RCC is a 68 Ga PSMA-positive tumor; the synchronous combination of RCC with prostate cancer can be confusing and requires more complex clinical interpretation.