In asymptomatic patients with castrate resistant prostate cancer who have failed chemotherapy and have progressive vertebral body metastases, when do you prescribe lutetium-177 vs prophylactic spinal radiation?

Goals are different.

Pluvicto is administered to improve pain, PFS, OS, and quality of life so it is SOC for patients who fail chemotherapy and have PSMA avid disease while good prophylactic RT is to prevent local bone-related events only.

Agree with Dr. @Dr. First Last and really this boils down to the patient in front of you. Diffuse pain correlating with diffuse bony lesions may benefit more from lutetium. If just focal pain then focal RT may make more sense (especially if med onc wants to try other systemic therapy regimens prior ...

Agree with the discussion surrounding focal radiotherapy, especially in patients with high-risk disease and limited involvement of the spinal column.

If safe and feasible, we favor prophylactic SBRT over conventional radiotherapy given improvements in local control and re-irradiation rates.