PET imaging and radionuclide therapy in neuroendocrine prostate cancer: a systematic review.

[INTRODUCTION] Neuroendocrine prostate cancer (NEPC) is a rare cancer subtype with significant prognostic implications. This systematic review aims to explore the current landscape of positron emission tomography (PET) imaging and radionuclide therapy in this rare entity.

[EVIDENCE ACQUISITION] The Scopus and PubMed online databases were systemically reviewed to identify relevant studies on the topic of interest.

[EVIDENCE SYNTHESIS] A total of 60 studies reporting such evidence in 102 patients were retrieved. A total of 179 PET/CT examinations were performed across all NEPC patients, with [F]Fluorodeoxyglucose ([F]FDG) being the most frequently utilized radiotracer (45% of NEPC patients), followed by [Ga]Ga-DOTA-peptides (22%), [Ga]Ga-prostate specific membrane antigen ([Ga]Ga-PSMA) (18%), and other PET tracers (15%). Single-modality PET/CT imaging was mostly employed to evaluate NEPC extent, detect unusual metastatic sites, assess therapy response, and guide for biopsy sites in cases of hormone-secreting NEPC. Multimodal PET/CT utilizing dual- or triple-tracer approaches was employed for collective NEPC interpretation, assessment of heterogeneity, therapy response assessment, and determination of radionuclide therapy eligibly. For treatment, 16 [Lu]Lu-DOTATATE cycles, administered to 7 patients, produced effective disease control in all patients. One patient received both [Lu]Lu-PSMA and [Lu]Lu-DOTATATE, achieving partial response, while another patient receiving 4 [Lu]Lu-PSMA cycles also showed a partial response.

[CONCLUSIONS] The multimodal molecular imaging approach appears to be the most effective for NEPC evaluation and determination of radionuclide therapy eligibility. [Lu]Lu-based therapies seem to be a compelling treatment approach to be pursued in eligible cases, although larger studies are needed to confirm the current findings.