Misadministration of 177Lu-DOTATATE Instead of 177Lu-PSMA in a Patient With Prostate Cancer: Clinical Implications and Management

Mohammad Hadi Samadi; Pegah Sahafi; Susan Khezri; Zahra Fazeli; Atena Aghaee

doi:10.1097/RLU.0000000000005711

Misadministration of 177Lu-DOTATATE Instead of 177Lu-PSMA in a Patient With Prostate Cancer: Clinical Implications and Management

Clin Nucl Med. 2025 Apr 16. doi: 10.1097/RLU.0000000000005711. Online ahead of print.

Authors

Mohammad Hadi Samadi¹, Pegah Sahafi¹, Susan Khezri², Zahra Fazeli¹, Atena Aghaee¹

Affiliations

¹ Nuclear Medicine Research Center, Mashhad University of Medical Science.
² Department of Internal Medicine, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.

PMID: 40237353
DOI: 10.1097/RLU.0000000000005711

Abstract

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 177Lu-PSMA therapy in the setting of metastatic castration-resistant prostate cancer (mCRPC). In the second session of the treatment, misadministration of 177Lu-DOTATATE instead of 177Lu-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.

Keywords: 177Lu-DOTATATE; 177Lu-PSMA; maladministration; medical error; medical event; pitfalls.