Imaging tumor lactate is feasible for identifying intermediate- risk prostate cancer patients with postsurgical biochemical recurrence

While radical prostatectomy remains the mainstay of prostate cancer (PCa) treatment, 20 to 40% of patients develop postsurgical biochemical recurrence (BCR). A particularly challenging clinical cohort includes patients with intermediate -risk disease whose risk stratification would benefit from advanced approaches that complement standard -of -care diagnostic tools. Here, we show that imaging tumor lactate using hyperpolarized 13C MRI and spatial metabolomics identifies BCR- positive patients in two prospective intermediate -risk surgical cohorts. Supported by spatially resolved tissue analysis of estab-lished glycolytic biomarkers, this study provides the rationale for multicenter trials of tumor metabolic imaging as an auxiliary tool to support PCa treatment decision- making.