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

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