Introduction: Only 20-40% of patients respond to therapy with immune checkpoint inhibitors (ICIs). Therefore, the early identification of subjects that can benefit from such therapeutic regimen is mandatory. Areas covered: The immunobiological mechanisms of ICIs are briefly illustrated. Furthermore, the limitations of traditional radiological approaches are covered. Then, the pros and cons of molecular imaging through positron emission computed tomography (PET/CT) are reviewed, with a particular focus on 18f-fluorodeoxyglucose (18F-FDG) and PET-derived metabolic parameters. Lastly, translational perspective of radiopharmaceuticals others than 18F-FDG such as 89zirconium (89Zr) or fluorine-18 (18F) labeled monoclonal antibodies (e.g.89Zr-atezolizumab, 89Zr-nivolumab) binding to specific biomarkers are discussed. Expert opinion: Molecular imaging presents a prominent role for the management of oncological patients treated with ICIs. Preliminary clinical data indicate that PET/CT with 18F-FDG is useful for assessing the response to treatment and for the imaging of immune-related adverse effects. Nevertheless, the methodological approach (iPERCIST, PERCIMT, or others) to be used for an optimal diagnostic accuracy and patients' evaluation is still a debated issue. PET/CT with radioligands directed toward ICIs biomarkers, although is still in a translational phase, holds the promise of accurately predicting the response to treatment and revealing the acquired resistance to immunotherapy.
Keywords: 18F-fluorodeoxyglucose; 89Zr-monoclonal antibodies; Immunotherapy; PET/CT; immune checkpoint inhibitors; immunoPET; metabolic parameters; theranostics.