Case Report: Evolution of intratumoral spatial heterogeneity assessed by [68Ga]Ga-DOTA-NOC PET/CT during dinutuximab beta therapy in pediatric high-risk neuroblastoma.
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Neuroblastoma, an embryonal neuroendocrine tumor, exhibits substantial biological heterogeneity and frequently expresses somatostatin receptors (SSTRs). Consequently, [68Ga]Ga-DOTA-NOC PET/CT is utilized as a targeted functional imaging modality to evaluate SSTR expression, though its utility in monitoring responses to multimodal immunotherapy remains complex. We report a 4-year-old male with high-risk neuroblastoma (Stage M) evaluated via serial [68Ga]Ga-DOTA-NOC PET/CT. Baseline imaging revealed a retroperitoneal tumor [maximum standardized uptake value (SUVmax) 6.5] and skeletal metastases. Following four cycles of induction chemotherapy combined with dinutuximab beta, a post-therapeutic PET/CT performed prior to surgical resection revealed that the primary mass structurally regressed and skeletal lesions resolved. However, a focal region within the residual primary tumor exhibited a discordant radiotracer uptake increase (SUVmax rising from 3.1 to 17.4). Histopathological evaluation confirmed this hyper-avid region as a viable, poorly differentiated neuroblastoma subclone. Consequently, while [68Ga]Ga-DOTA-NOC PET/CT assists in localizing viable residual disease and guiding surgical navigation, elevated SSTR accumulation following immunotherapy necessitates cautious multidisciplinary evaluation.