Radiomics and theranostics with molecular and metabolic probes in prostate cancer: toward a personalized approach

IntroductionIn the last decade, two new radionuclide-based therapies, (223)Radichloride and radioligand therapy (RLT) targeting prostate-specific membrane antigen (PSMA), have been approved by the regulatory authorities for the management of castrate-resistant prostate cancer (PCa).Areas coveredThe basic principles of PCa molecular imaging are illustrated, with a particular attention to the combined use of diagnosis and therapy in a unique approach (the so-called theranostics) for response prediction and assessment in patients submitted to (223)Radichloride or PSMA targeted therapies. In this perspective, the potential of radiomics, an emerging discipline based on the extraction of quantitative features from medical images, is covered.Expert opinionTheranostic metabolic and molecular probes have been successfully applied to predict and monitor response to radionuclide-based therapies. In particular, both Tc-99m-MDP and F-18-NaF resulted useful tools for personalized dosimetry and prognostic stratification before Ra-223-therapy, while PSMA-ligands, alone or in combination with F-18-FDG, provided valuable information to select patients who are more likely to benefit from RLT and getting information on PCa grade of differentiation and aggressiveness. In spite of its high potential, PET-radiomics for PCa is still at an embryonic phase and needs further validation.