Radiometabolic Therapy in Lymphoma: From Radioimmunotherapy to Emerging Theranostic and Combination Strategies

Radiometabolic therapy is a mechanistically plausible but clinically underused strategy in lymphoma. Its rationale is based on the selective delivery of cytotoxic radiation to malignant lymphoid cells through antibodies, peptides, or small molecules directed against tumor-associated targets. Radioimmunotherapy with anti-CD20 agents, including 90Y-ibritumomab tiuxetan and 131I-tositumomab, demonstrated meaningful efficacy in B-cell non-Hodgkin lymphoma, particularly in indolent and relapsed/refractory settings. However, despite encouraging clinical results, its use progressively declined because of logistical, regulatory, commercial, and multidisciplinary barriers. More recently, renewed interest has emerged with the development of novel antibody-radionuclide conjugates and radioligand-based theranostic strategies targeting CD22, CD37, CD45, and CXCR4. Among these, CXCR4-directed imaging and therapy with 68Ga-pentixafor and 177Lu/90Y-pentixather illustrate image-guided patient selection and targeted radionuclide treatment in advanced hematologic malignancies. This narrative review summarizes evidence retrieved from Scopus and PubMed on radiometabolic therapy in lymphoma, with particular attention paid to established radioimmunotherapy, emerging targets, radioligand therapy, dosimetry, toxicity, and combination strategies with chemotherapy, immunotherapy, and hematopoietic stem cell transplantation. Available evidence supports the plausibility and possible clinical utility of these approaches, but remains heterogeneous and, for several newer targets, preliminary. Future development will require prospective trials, standardized imaging-based selection, individualized dosimetry, and integration within multidisciplinary lymphoma treatment pathways.