We present a rare variant of prostate carcinoma. The patient is a 45-year-old male with elevated prostate-specific antigen levels at screening. Magnetic resonance imaging revealed hyperenhancing lesions throughout the axial skeleton. The fluorine-18 fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) scan showed no abnormal bone findings. Subsequently, a technetium-99 methydiphosphonate (Tc99m-MDP) bone scan was performed, with additional correlative single-photon emission computed tomography (SPECT)/CT imaging of the pelvis and the results were essentially normal. A percutaneous core biopsy of one of the bone lesions in L5 was performed and histology confirmed small cell (neuroendocrine) variant of prostate cancer. Our case illustrates a possible pitfall in molecular imaging of prostate carcinomas, whereby both bone scintigraphy and FCH PET/CT scans showed no definite bone lesions to correlate with marrow signal abnormalities seen on MR imaging. This highlights the need for caution in the diagnostic evaluation of prostate cancers with known small cell variants.

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