Targeted Radiation, Unintended Evolution.

Radioligand therapy exemplifies precision oncology, yet its consequences remain incompletely understood. A recent article shows that [177Lu]Lu-PSMA promotes emergence and expansion of clonal hematopoiesis enriched for DNA damage response gene mutations, reframing bone marrow effects as treatment-emergent clonal selection rather than collateral toxicity and informing biology-guided patient monitoring and theranostics. See related article by Munzur et al., p. 2644.