The aim of the study was to assess the correlation between metabolic response measured through positron emission tomography-computed tomography (PET-CT) with 18F choline (18F FCH) and overall survival (OS) in patients affected by bone lesions from metastatic castration-resistant prostate cancer treated with 223Ra dichloride. Eleven subjects were subjected to PET-CT with 18F FCH before and 1 month after 223Ra treatment. Reduction in total lesion activity (ΔTLA) between pretreatment and post-treatment scan was determined and patients were divided into responders (ΔTLA >50%) and nonresponders (ΔTLA <50%). The OS of the entire cohort was 12.7 ± 3.8 months. Kaplan-Meier analysis showed that responders presented a significantly longer survival than nonresponders (16.5 ± 1.9 months vs. 10.5 ± 0.9 months, p < 0.05). Reduction in TLA after 223Ra treatment seems to be correlated with a trend toward a longer survival.