New generation prostate cancer imaging (PET/SPECT): systematic review of diagnostic and therapeutic roles

Objectives: To systematically evaluate the role and clinical application of nuclear imaging in contemporary prostate cancer (PCa) management across all disease phases, including initial staging, detection of biochemical recurrence (BCR), assessment of oligometastatic disease, and guidance of theranostic treatment. Material and methods: A systematic literature search was performed in MEDLINE, Web of Science, and Scopus for English-language human studies published from January 2013 to August 2025. Studies evaluating nuclear imaging techniques—including conventional modalities (bone scintigraphy, SPECT) and new-generation PET tracers (e.g. PSMA ligands, 18F-fluciclovine, choline)—were included. Outcomes analyzed included diagnostic performance, impact on management, and clinical utility across the disease spectrum. The review followed PRISMA guidelines and used structured methods based on a predefined protocol. Results: A total of 6,854 records were identified (2,310 in MEDLINE, 2,478 in Web of Science, and 2,066 in Scopus), with 1,432 duplicates removed. After screening, 312 full-texts were reviewed, and 34 studies met inclusion criteria. PSMA PET/CT demonstrated superior diagnostic accuracy in high-risk staging and BCR settings compared to conventional imaging, with detection rates exceeding 85% in some studies and management changes reported in 30–75% of cases. In oligometastatic PCa, PET-guided metastasis-directed therapy prolonged progression-free survival. Nuclear imaging also enabled patient selection for radioligand therapy, notably 177Lu-PSMA-617, with demonstrated survival benefit in the VISION trial. Conclusions: Nuclear imaging, especially PSMA-targeted PET, has revolutionized prostate cancer management by enhancing diagnostic precision and enabling personalized treatment. Integration into clinical practice is justified by strong evidence of improved staging, recurrence detection, therapeutic planning, and patient outcomes.