MR-based techniques for imaging prostate cancer metabolism: current status and future perspectives

Prostate cancer (PCa) is a heterogeneous disease ranging from indolent to highly aggressive forms (e.g., castration-resistant PCa). Although multiparametric MRI plays an important role in the routine diagnosis and management of PCa, emerging challenges underscore a critical unmet need in the era of precision and personalized medicine. Given that metabolic reprogramming is a hallmark of PCa, metabolic imaging techniques that focus on and target changes in metabolic pathways, such as PET and hyperpolarized (HP) ¹³C MRI, represent critical tools for facilitating early diagnosis, risk stratification, and monitoring of PCa treatment. This review discusses the metabolic characteristics of PCa, the current landscape of MR-based metabolic imaging techniques, and their applications to PCa, with a particular emphasis on recent advances in proton magnetic resonance spectroscopy imaging (¹H-MRSI), HP ¹³C MRI, and other emerging advanced MRI techniques, including chemical exchange saturation transfer (CEST) MRI, sodium (²³Na) MRI, and deuterium metabolic imaging (DMI). Additionally, we discuss the challenges and future perspectives for their further clinical translation.