Success and Limitations of PSMA RLT : The Nuclear Medicine View.

Lutetium-177 PSMA radioligand therapy (RLT) represents a paradigm shift in advanced prostate cancer care, establishing a precision oncology standard through its inherent theranostic capability. From a nuclear medicine perspective, its defining success lies in the ability to precisely select patients and offer targeted cytotoxic delivery of radiation, resulting in high objective response rates and quality-of-life improvements, particularly rapid pain palliation. A collaborative view with medical oncology highlights critical limitations. Despite frequent favourable initial responses, disease recurrence is almost universally inevitable, demonstrating a modest survival benefit in randomised trials and possibly limited control over micrometastatic or heterogeneous disease. The future requires bridging this gap through interdisciplinary research: leveraging molecular imaging for adaptive treatment strategies, evaluating earlier-line use, and developing synergistic combinations and next-generation isotopes, including Auger/conversion electron and alpha emitters, to maximise clinical benefit and achieve durable responses.