Editorial: Recent advances in theranostics: endocrine tumours and beyond

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In recent decades, radionuclide therapy has undergone substantial development, proving effective in the treatment of various oncological conditions. Available therapies range from established treatments, such as radioiodine therapy for differentiated thyroid cancer [1], to more recently developed approaches for neuroendocrine tumours (NETs) [2,3], prostate cancer [4], and cutaneous malignancies [5]. In this context, theranostics-the ability to use the same molecular carrier for both diagnostic characterization and targeted therapyrepresents an increasingly relevant approach in nuclear medicine. Recent Nevertheless, authors point out that, in selected clinical situations, including serotoninsecreting lesions, equivocal SSTR imaging, or specific functional tumours, DOPA-PET may provide complementary information. Thus, these findings reinforce the concept that imaging should increasingly be adapted to the biological characteristics of individual tumours rather than relying on a single imaging strategy, within a patient tailored oncological approach.Considering the growing development of theranostic aspects in the field of prostate cancer, Albano et al. performed a systematic review and meta-analysis evaluating the diagnostic role of [ 99m Tc]Tc-PSMA SPECT/CT. Twenty-three studies involving 1,840 patients were included, with 19 studies contributing to the meta-analysis. The pooled detection rate (DR) was 79.7% in the staging setting and 75.4% in patients with biochemical recurrence.Importantly, PSA levels were frequently associated with the DR. Although significant heterogeneity was observed among the included studies, these results support the potential role of SPECT/CT as an alternative diagnostic approach, particularly in clinical contexts worldwide where PET/CT is not readily available [6]. This aspect is particularly relevant because the future development of theranostics will depend not only on biological effectiveness but also on the possibility of making advanced molecular imaging and targeted treatments accessible across different healthcare environments [7].The therapeutic counterpart of PSMA-targeted imaging is discussed in the narrative review by Gierulska et al., which summarizes current evidence on [ 177 Lu]Lu-PSMA-targeted radioligand therapy (RLT), emerging [ 225 Ac]Ac-PSMA strategies, and therapeutic sequencing in advanced prostate cancer. The review highlights the established role of [ 177 Lu]Lu-PSMA in selected patients with metastatic castration-resistant prostate cancer (mCRPC), as demonstrated by pivotal trials including VISION, TheraP, and PSMAfore [4,8,9]. In particular, the PSMAfore trial supports the potential benefit of introducing [ 177 Lu]Lu-PSMA RLT earlier in the disease course, before taxane-based chemotherapy, in selected taxane-naïve patients. At the same time, emerging alpha-emitting approaches such as [ 225 Ac]Ac-PSMA may offer additional therapeutic opportunities, although definitive phase III evidence is still lacking. These developments underline that theranostics is progressively moving towards the optimization of treatment timing, radionuclide selection, toxicity management, and therapeutic sequencing.Finally, Sadeghpour et al. broadened the application of targeted radionuclide therapy to cutaneous malignancies by systematically reviewing the available evidence on rheniumassisted therapy for skin lesions. Their review and meta-analysis included 10 studies, encompassing a total of 433 patients and over 618 lesions. Among the seven studies included in the meta-analysis, rhenium-assisted therapy achieved a pooled complete response rate of 88.67% and an overall response rate of 92.9%. Although these findings are encouraging, the authors appropriately emphasize the need for further studies and standardized treatment protocols. This contribution is particularly relevant in demonstrating how radionuclide-based approaches may extend beyond the more established fields of endocrine and prostate malignancies and potentially provide minimally invasive therapeutic options for selected patients with cutaneous tumours. A central challenge for the next phase of theranostics will be to move beyond a binary assessment of target expression. Molecular imaging should increasingly be regarded as a dynamic biomarker, capable of revealing spatial and temporal heterogeneity and changes induced by disease progression or treatment. Longitudinal imaging could therefore guide patient selection, treatment adaptation, and the identification of patients who may benefit from alternative radiopharmaceuticals or combined therapeutic strategies. Future progress will also depend on integrating molecular imaging with circulating biomarkers, molecular profiling, conventional imaging, and patient-specific dosimetry [10].Such integration could support a transition from standardized treatment schedules towards more individualized decisions regarding administered activity, treatment intervals, number of cycles, radionuclide selection, and therapeutic sequencing. Advanced quantitative imaging and artificial intelligence may facilitate this process, provided that these approaches undergo robust multicentre validation and methodological harmonization.Finally, innovation in theranostics must be accompanied by attention to clinical evidence, feasibility, and equitable access. Prospective comparative trials, standardized response criteria, long-term toxicity assessment, and health-economic analyses will be essential to determine the added value of emerging strategies [11]. The maturation of theranostics will depend not only on new radiopharmaceuticals, but also on their integration into multidisciplinary, evidence-based, and widely implementable clinical pathways.

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.