Multiprobe PET Imaging: Insignia of Tumor Heterogeneity in a Case of Neuroendocrine Prostate Cancer

Neuroendocrine prostate cancer (NEPC) is an aggressive subtype of prostate cancer, often developing from androgen receptor (AR) independence, characterized by neuroendocrine molecular markers and nonresponsiveness to standard treatments of prostate adenocarcinoma. The evolution of adenocarcinoma to NEPC is characterized by epigenetic changes, leading to the downregulation of the PSMA transmembrane protein, as well as the upregulation of FDG-uptake pathways and somatostatin receptor expression. We present a case of NEPC that depicts a significant metastatic intertumoral heterogeneity as depicted on PSMA, FDG, and DOTATATE PET/CT scans. Such multiprobe PET evaluation of NEPC may assist in sampling the most aggressive disease and guide an appropriate management strategy. It also provides a cellular-level insight into this dreadful disease with very limited treatment options.