The role of PET and SPECT imaging in prostate cancer targeted Alpha therapy: when and how?

This review discusses the current state of Targeted Alpha Therapy (TAT) in prostate cancer, particularly in mCRPCT (metastatic castration-resistant prostate cancer). This review describes the widely used Radium-223 and the novel trend in the TAT field with a special focus on prostate-specific membrane antigen (PSMA)-based alpha therapy. With this in-depth discussion on the growing field of PSMA-based alpha therapy, we aim also to analyze the most useful diagnostic tools in the patient selection and in the treatment monitoring. We explored the diagnostic tools used in clinical practice and in research settings in order to clarify the imaging procedures that may support the PSMA-based TAT management, including both the patient's selection and the therapy response monitoring, with a special focus on diagnostic PSMA-PET/CT imaging. Further multicenter trials are needed, but a better understanding of the strengths and limitations of molecular imaging in PSMA-based TAT management may help in creating an effective therapeutic algorithm for mCRPC and designing a rational approach to treatment.