Treatment response assessment according to updated PROMISE criteria

The advent of prostate-specific membrane antigen (PSMA) positron emission tomography (PET) imaging has revolutionized the evaluation and management of prostate cancer, enabling superior lesion detection and characterization across various disease stages. In response to the growing need for standardized interpretation, the Prostate Cancer Molecular Imaging Standardized Evaluation (PROMISE) criteria were introduced in 2018, offering a structured approach to staging and risk assessment. As PSMA-targeted imaging becomes more central in response assessment and theranostics, updated PROMISE criteria have been proposed to reflect treatment-related changes and incorporate newer therapies like PSMA radioligand therapy (RLT). This review provides an in-depth overview of the updated PROMISE criteria, highlighting key changes, their rationale, and their application in assessing treatment response. Comparative discussion with other response criteria, including RECIST, PERCIST, and RECIP, is included. We also address practical challenges, potential pitfalls, and future directions for integrating PROMISE with emerging technologies such as artificial intelligence and radiomics. By refining response evaluation in prostate cancer, the updated PROMISE criteria represent a significant step toward precision imaging and personalized therapy.