Fig. 7.

A patient with the organ of Zuckerkandl metastatic paraganglioma with progression on three lines of chemotherapy, three lines of targeted therapies and immunotherapy was referred for radionuclide therapy. ¹²³I-MIBG planar imaging (A) showed intense uptake in the organ of Zuckerkandl (arrows) and a limited number of bone metastases compared to far more extensive bone metastases and lymphadenopathy in the bilateral posterior neck (brackets) on a contemporaneous ¹⁸F-FDG PET (B). Therefore, the patient was not considered suitable for treatment with ¹³¹I-MIBG. ⁶⁸Ga-DOTATATE PET (C) showed high tracer avidity (Krenning score 4) in most sites of disease similar in distribution to ¹⁸F-FDG PET, hence the patient was deemed suitable for ¹⁷⁷Lu-DOTATATE. The post-treatment ¹⁷⁷Lu-DOTATATE SPECT (D) showed moderate to intense uptake in the primary site and lymphadenopathy while the vast majority of bone metastases retain only mild to moderate tracer uptake (Krenning score 2–3). The patient developed progressive pancytopenia, which combined with the low post-treatment radiotracer uptake, did not advance with further cycles of ¹⁷⁷Lu-DOTATATE. ¹⁸F-FDG PET (E) 2 months post-¹⁷⁷Lu-DOTATATE showed further progression of the disease