Background: German guidelines recommend ¹⁷⁷Lu-PSMA-617 only for treatment of patients with castrate resistant metastatic prostate cancer after failure with present life-prolonging treatments. Therefore, only few patients with chemotherapy-naïve hormone-resistant oligometastatic prostate cancer have been reported.  Some of the patients obtained long-lasting complete remission.  

Case report: A 50 year old Danish patient with prostate cancer underwent radical prostatectomy June 2007. He had a large prostate cancer with invasion of seminal vesicles, positive surgical margins and bilateral metastases to 3 pelvic lymph nodes (_pT3 R1, _pN1, M0, Gleason score 9 (5 + 4)). Post-operatively he was given androgen deprivation therapy. He developed a PSA recurrence in 2011 with a metastatic lesion in a single pararectal lymph node. He underwent volumetric modulated arc therapy (VMAT), and obtained a partial PSA remission. In 2014, he developed a second PSA recurrence with two new sites in retroperitoneal lymph nodes. Then he was treated with a combination of Abiraterone and VMAT and obtained a partial PSA remission. In March 2016, he developed a third PSA recurrence with increase of PSA from 0.3 to 0.5 ng/ml.  The patients had no symptoms. July 2016 68Ga-PSMA HBED-CC PET/CT showed a new site in a mediastinal lymph node. Thereafter the patient started ¹⁷⁷Lu-PSMA-617 therapy.

Discussion: During three episodes of PSA recurrence for this patient, salvage treatment guided by PET/CT imaging gave five more years with very low PSA values and disease limited to the lymphatic system. In addition to phase II and phase III trials of ¹⁷⁷Lu-PSMA-617 for chemotherapy-naïve castrate-resistant patients with oligometastatic prostate cancer, head-to-had analysis of case reports elucidates the efficacy with salvage ¹⁷⁷Lu-PSMA-617 comparing the level and duration of response with this treatment and with previous salvage treatments.