Imaging-guided use of combined ¹⁷⁷Lu-DOTATATE and capecitabine therapy in metastatic mediastinal paraganglioma

Peptide receptor radionuclide therapy targets highly expressed somatostatin receptors in well-differentiated neuroendocrine tumors, producing stability or a partial response in most patients with inoperable or metastatic disease. However, neuroendocrine tumors showing increased ¹⁸F-FDG uptake have limited treatment options and a poor outcome, and the role of peptide receptor radionuclide therapy is still unclear. Here, we present the case of a young man with mediastinal paraganglioma and extensive metastatic disease showing avidity on both somatostatin receptor imaging and ¹⁸F-FDG imaging. The patient experienced a partial response to peptide receptor chemoradionuclide therapy (¹⁷⁷Lu-DOTATATE and low-dose capecitabine), as well as a significantly improved quality of life. This case highlights the utility of peptide receptor chemoradionuclide therapy when there is extensive disease avid for both somatostatin receptor and ¹⁸F-FDG and a lack of other suitable treatment modalities.