Scanning Methods and Treatment Selection

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Imaging modality selection plays a crucial role in treatment planning and monitoring for patients with mCRPC, with different scanning methods offering distinct advantages for specific clinical scenarios. Traditional imaging approaches include CT scans with intravenous contrast and bone scans for baseline assessment and treatment monitoring, helping clinicians determine disease progression and treatment response over time. These conventional methods remain standard for most mCRPC treatment decisions and have proven effective in clinical trial settings, including the registration trials that led to the approval of radium-223.

PSMA PET scanning represents an emerging technology with specific applications in mCRPC management, primarily used when considering PSMA-targeted therapies, such as lutetium lu-177 PSMA-617 (Pluvicto). Although PSMA PET scans are not yet standardized for routine monitoring of treatment response or progression, they offer superior sensitivity for detecting soft tissue metastases that might be missed on conventional imaging. A notable study by Bosch et al suggested that PSMA PET scanning might help identify patients with truly bone-only disease for radium therapy, potentially improving patient selection and treatment outcomes.

The clinical implications of imaging choice depend on treatment intent and patient characteristics. For radium-223 therapy, patients should have predominantly bone metastases with minimal soft tissue involvement, criteria that can generally be assessed with CT and bone scans. However, PSMA PET scanning may provide more precise patient selection by identifying occult soft tissue disease. Future developments in PSMA PET imaging may establish standardized criteria for monitoring treatment response, potentially expanding its role in routine mCRPC management beyond patient selection for PSMA-targeted therapies.