Key result
Misadministered 177Lu-DOTATATE instead of 177Lu-PSMA in mCRPC shows faint uptake in prostate and skeletal metastases.
Case Report (n=1)
This case highlights the critical need for robust safety protocols and the reporting of medical errors to prevent radiopharmaceutical misadministration in nuclear medicine.
Faint uptake after misadministration warrants caution in radiopharmaceutical handling; leaves open possible SSTR expression in mCRPC for prospective study.
We present a 62-year-old man with a history of very high-risk prostate cancer (Gleason score: 4+3 in 12 of 12 cores) and widespread skeletal metastases was referred for 177 Lu-PSMA therapy in the setting of metastatic castration-resistant prostate cancer (mCRPC). In the second session of the treatment, misadministration of 177 Lu-DOTATATE instead of 177 Lu-PSMA occurred. Post-treatment Lutetium whole body scan and SPECT/CT showed faint uptake in the prostate gland and seminal vesicles with skeletal metastases. Our case emphasizes the importance of encouraging colleagues to report medical errors and concerns about safety protocols for minimizing errors in the nuclear medicine department.
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Samadi et al. (2025) conducted a case report in metastatic castration-resistant prostate cancer (mCRPC) (n=1). 177Lu-DOTATATE vs. 177Lu-PSMA was evaluated on Uptake on post-treatment Lutetium whole body scan and SPECT/CT. Misadministration of 177Lu-DOTATATE instead of 177Lu-PSMA in a 62-year-old man with mCRPC showed faint uptake in the prostate gland, seminal vesicles, and skeletal metastases.
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