ESUR: Opportunities for PSMA-PET/CT and whole-body MRI in advanced prostate cancer

Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) computed tomography (CT), and whole-body magnetic resonance imaging (WB-MRI) are superior to conventional CT and bone scan imaging for detecting metastatic disease in patients with prostate cancer. While these higher-accuracy imaging methods have already shown the potential to enhance patient outcomes, a thorough understanding of the relationship between the treatment landscape and disease volume on conventional imaging, as well as the prognostic significance of the prostate-specific antigen response, is crucial for determining how they can be more effectively incorporated. Prospective clinical trials are required to evaluate whether PSMA-PET/CT and WB-MRI can genuinely improve clinically relevant endpoints for patients through precise treatment adaptations. In this paper, we explore the specific opportunities of PSMA-PET/CT and WB-MRI as biomarkers in multiple clinical domains, including metastasis detection and staging, disease characterisation and aggressiveness assessments, biopsy target selection, impacts on treatment planning, evaluation of therapeutic response, and theranostics. We highlight the central research questions that require attention. KEY POINTS: Question Can PSMA-PET/CT and WB-MRI, with their superior ability to detect metastases in prostate cancer, truly improve patient outcomes? Findings High-accuracy imaging improves metastasis detection, staging, assessment of disease aggressiveness, and enables more personalised treatment planning for advanced prostate cancer patients. Clinical relevance PSMA-PET/CT and WB-MRI have the potential to alter the management of men with advanced prostate cancer, but prospective clinical trials are needed to confirm benefits for survival or quality of life before recommending routine use.