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Its prognostic relevance in patients with metastatic castration-resistant prostate cancer (mCRPC) undergoing [\u00b9\u2077\u2077Lu]Lu-PSMA-617 radioligand therapy has not yet been systematically evaluated. This study aims to investigate the prognostic value of SMD derived from routine pretherapeutic PET\/CT imaging in a large real-world mCRPC cohort treated with [\u00b9\u2077\u2077Lu]Lu-PSMA-617.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>In this single-center study, the largest to date cohort comprising 410 mCRPC patients was analyzed. SMD was quantified automatically from the L3-level CT component of pretherapeutic [\u2076\u2078Ga]Ga-PSMA-PET\/CT using an AI-based segmentation tool. An optimal SMD cut-off (19.26 HU) was determined for survival stratification. Associations with overall survival (OS) were assessed using multivariable Cox regression (univariable and multivariable, adjusted for baseline PSA) and Kaplan-Meier analysis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Lower SMD was associated with reduced OS (HR 1.87,\n                      <jats:italic>P<\/jats:italic>\n                      &lt;.001). Median OS were significantly shorter in the SMD-low group compared to the SMD-high group (7.6 months vs. 12.2 months;\n                      <jats:italic>P<\/jats:italic>\n                      &lt;.001). This prognostic stratification was seen in both, patients with or without PSA50 or PSA90 response, respectively. SMD correlated with age, albumin, and PSA, but not with BMI.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>SMD assessed from routine pretherapeutic PET\/CT is a non-invasive prognostic biomarker in patients undergoing PSMA-targeted radioligand therapy. Integration of host-derived imaging biomarkers such as SMD with tumor-specific parameters may improve risk stratification, prehabilitation and support future individualized treatment strategies in advanced prostate cancer.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00259-026-08068-x","type":"journal-article","created":{"date-parts":[[2026,7,22]],"date-time":"2026-07-22T08:06:40Z","timestamp":1784707600000},"page":"7194-7203","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Skeletal muscle radiodensity as an automated survival predictor in men with metastatic castration-resistant prostate cancer undergoing PSMA-targeted radioligand therapy"],"prefix":"10.1007","volume":"53","author":[{"given":"Christian","family":"Immanuel","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"B\u00fcttner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alois M.","family":"Sprinkart","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Nowak","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maike","family":"Theis","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jim","family":"K\u00fcppers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sibgol","family":"Fazeli","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leander","family":"Fritzsche","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aland","family":"Amin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dilan","family":"Salih","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hojjat","family":"Ahmadzadehfar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Florian C.","family":"G\u00e4rtner","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barbara","family":"Kreppel","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rupert","family":"Conrad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Manuel","family":"Ritter","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Markus","family":"Essler","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp","family":"Krausewitz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1856-5005","authenticated-orcid":false,"given":"Milka","family":"Marinova","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,7,22]]},"reference":[{"issue":"6","key":"8068_CR1","doi-asserted-by":"publisher","first-page":"987","DOI":"10.1007\/s00259-014-2978-1","volume":"42","author":"C Kratochwil","year":"2015","unstructured":"Kratochwil C, et al. 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The study was registered by the German Clinical Trial Register (DRKS00035087) and was approved by the institutional review board of the University Hospital Bonn (Ethics Committee vote 2024-19-BO), with a waiver of informed consent because of the retrospective study design.","order":1,"name":"Ethics","label":"Ethics approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Thomas B\u00fcttner received speaker honorary from Astellas. Philipp Krausewitz received speaker honorary from Novartis and Johnson and Johnson. The other authors have no competing interests to declare that are relevant to the content of this article.","order":2,"name":"Ethics","label":"Competing interests","group":{"name":"EthicsHeading","label":"Declarations"}}]}}