Lineage plasticity-driven immunometabolic state transitions in advanced prostate cancer: biomarkers and therapeutic stratification.

Advanced prostate cancer is commonly described as immunologically cold, yet that label obscures a disease continually remodelled by treatment. Androgen-receptor (AR) pathway inhibition, chemotherapy, DNA-damage-directed therapy and radioligand treatment select resistant clones while altering lineage identity, metabolic dependence, antigen presentation and metastatic niches. AR-high, AR-low, double-negative, amphicrine and treatment-emergent neuroendocrine phenotypes are therefore better viewed as evolving immunometabolic states than as fixed histologies. Here, we develop a lineage-metabolism-immunity framework that integrates metastatic biopsies, longitudinal sampling, single-cell and spatial analyses, functional imaging and mechanistic prostate cancer models. Lineage determines which metabolic programmes remain available; tumour, stromal and immune cells then compete for nutrients and exchange metabolites that shape antigen presentation, myeloid suppression and lymphocyte function. We focus on glucose and lactate, lipids, amino acids, hypoxia-adenosine signalling and epigenetically active metabolites, while separating patient evidence from causal prostate cancer models and pan-cancer inference. The framework reframes three clinical tasks: identifying the state driving progression, recognising transitions under therapy and selecting combinations that relieve the dominant immune bottleneck without disabling effector cells. Translation will require longitudinal, lesion-aware measurements that connect lineage markers to functional evidence of metabolic dependence and immune context. The goal is not a universal metabolic target, but a tractable intervention matched to the tumour state, metastatic site and therapeutic window.