We present the case of a patient with heavily pretreated metastatic castration-resistant prostate cancer (mCRPC) who underwent treatment with lutetium Lu-177 vipivotide tetraxetan (also known as 177Lu-PSMA-617) due to progressive disease despite multiple lines of therapy, including chemotherapy, hormonal therapy, and radiation, encompassing palliative mediastinal and central nervous system radiation.
The patient was subsequently hospitalized due to worsening acute onset dyspnea, despite showing a clinical response to the treatment. Interval CT imaging revealed progressive multifocal ground-glass opacities superimposed on a pre-existing peribronchovascular fibrosis. An exhaustive evaluation to identify a potential infectious cause was conducted, effectively excluding most differential diagnoses. While our case report details the possible causes for the patient’s dyspnea and associated radiographic findings that included radiation pneumonitis (RP), radiation recall pneumonitis (RRP), and drug-induced pneumonitis, we would like to additionally add the consideration of lymphangitic carcinomatosis. Despite prior PSMA PET scans failing to demonstrate PSMA-avid lesions in previously noted pulmonary nodules, key radiographic findings at the time of hospitalization that were also appreciated to present in LC include interlobular septal thickening and peribronchovascular thickening indicative of a "crazy paving" pattern.
Additional features potentially pointing towards LC, such as hilar and mediastinal lymphadenopathy, and pleural effusions, were also found. Thus, we would like to make the addendum to include lymphangitic carcinomatosis (LC) in the differential diagnosis due to its radiographic congruency with the observed imaging patterns, despite the absence of PSMA-avid lesions on prior PET scans. This addendum is prompted by the recognition that LC, as a manifestation of metastatic spread through the lymphatic system, may not always exhibit PSMA avidity, particularly in the context of heterogeneous tumor biology or prior extensive treatment. The inclusion of LC expands our diagnostic consideration to encompass the full spectrum of potential etiologies contributing to the patient's pulmonary manifestations.”
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Apalutamide for Metastatic Castration-Sensitive Prostate Cancer
"Early initiation of Lu-177 PSMA radioligand therapy prolongs overall survival in metastatic prostate cancer"
Phase I/II Trial Evaluation of Radioligand Treatment in Patients with Metastatic Castration-Resistant PCa with [161Tb]Tb-PSMA-I&T
