Boss Case
Follow a case through a sequence of decisions. Read the history, work through each stage, and finish with the case’s collected teaching points.
What you will practise
- Combine history with imaging findings.
- Make a sequence of reasoned decisions.
- Review the full case rather than only the score.
Choose a case
Each case includes staged questions and an end-of-case debrief.
Rising PSA after prostatectomy
68M with PSA rising to 0.4 ng/mL, 18 months after radical prostatectomy; conventional imaging is negative.
Progressing midgut NET
58F with a well-differentiated midgut neuroendocrine tumour, radiologically progressing on a long-acting somatostatin analogue.
The Progressing Carcinoid
A 62-year-old on long-acting octreotide for a well-differentiated midgut neuroendocrine tumour (Ki-67 8%) develops worsening diarrhoea and new liver lesions on surveillance CT.
The Exhausted Options
A 70-year-old with metastatic castration-resistant prostate cancer has progressed after docetaxel and an androgen-receptor pathway inhibitor; bone and nodal metastases are widespread.
The Slow PSA Climb
A 66-year-old man is four years out from radical prostatectomy for pT3a prostate cancer. His PSA, previously undetectable, has risen to 0.6 ng/mL over three consecutive measurements.
When PSMA Isn't Enough
A 72-year-old man with metastatic castration-resistant prostate cancer has progressed after an androgen-receptor pathway inhibitor and taxane chemotherapy. He is referred to assess further options.
The MIBG-Negative Child
A 4-year-old presents with an abdominal mass, bone pain, and elevated urinary catecholamines. Biopsy confirms high-risk neuroblastoma.
Progressive Midgut NET
A 62-year-old with a well-differentiated G2 metastatic midgut NET progresses on long-acting octreotide, with liver and nodal metastases on CT.
The Marrow-Packed Patient
A man with heavily pretreated metastatic castration-resistant prostate cancer has a rising PSA, widespread PSMA-avid skeletal disease and a leucoerythroblastic blood film. Diffuse tumour infiltration of the marrow and borderline blood counts had excluded him from a 177Lu-PSMA trial. His team asks whether alpha therapy is defensible - or reckless - in someone whose marrow is already failing.
The remnant that was too small
A 61-year-old man with Child-Pugh A5 cirrhosis (HCV, no ascites, normal bilirubin, no portal hypertension) has a solitary 6 cm HCC confined to the right hepatic lobe. Surgeons would resect, but volumetry estimates a future liver remnant (left lobe) of only 27%. You are consulted about a nuclear-medicine-based bridge to resection.
The PRRT That Stopped Working
A 54-year-old woman has a well-differentiated metastatic small-bowel neuroendocrine tumour with hepatic and skeletal spread. She completed four cycles of 177Lu-DOTATATE with initial stabilisation, but now has radiographic and symptomatic progression. Restaging 68Ga-DOTANOC PET/CT still shows intense somatostatin-receptor-avid disease.
The Metastasis FDG Missed
A 61-year-old man had a radical nephrectomy for clear cell renal cell carcinoma three years ago and now reports vague neurological symptoms. 18F-FDG PET/CT is unremarkable apart from a questionable parietal skull lesion read as a bone metastasis, and conventional imaging is equivocal.