Late 68Ga PSMA positive pancreatic metastasis from renal cell carcinoma in a patient with metastatic prostate cancer – a mission impossible

We present a case of a patient with a newly diagnosed high-risk prostate cancer. The patient had nephrectomy for renal cell carcinoma in 2009. The PSMA scan revealed primary tumor with seminal vessels involvement, PSMA positive regional lymph nodes, as well as several nodular lung lesions with mild PSMA uptake, PSMA positive mediastinal lymph nodes and a PSMA positive mass in the pancreatic head. An ultrasound guided biopsy was performed for the pancreatic lesions revealing metastasis from a renal cell carcinoma. Simultaneous treatment for prostate cancer and metastatic RCC was started. In order to separate metastatic sites for both primaries we attempted to use FDG PET CT - moderately positive for the pancreatic mass but not for the other locations.
RCC is a 68Ga PSMA positive tumor; the synchronous combination of RCC with prostate cancer can be confusing and requires more complex clinical interpretation.