Prostate-specific membrane antigen based diagnostic and therapeutic integration for prostate cancer management

Prostate-specific membrane antigen (PSMA)-based theragnostics has transformed precision oncology by integrating molecular imaging and targeted radionuclide therapy in prostate cancer (PCa). This review outlines the mechanistic rationale of PSMA targeting, radiopharmaceutical design, and diagnostic applications of ⁶⁸Ga-PSMA-11 positron emission tomography (PET)/computed tomography (CT) imaging. The sensitivity and specificity of ⁶⁸Ga-PSMA-11 PET/CT imaging are higher than those of conventional imaging. Randomized phase III trials have demonstrated that ¹⁷⁷Lu-PSMA-617 confers survival benefits to patients with metastatic castration-resistant PCa. Meanwhile, emerging α-emitter therapies, such as ²²⁵Ac-PSMA-617, exert potent cytotoxic effects in resistant disease but are associated with xerostomia as a dose-limiting toxicity and production constraints. Dosimetry, patient selection, and toxicity management are critical to optimize therapeutic outcomes. Novel approaches, including bispecific antibodies and nanobody-based agents, along with combination regimens and ongoing randomized trials, are expected to refine treatment strategies and extend applications. PSMA-based theragnostics are associated with challenges related to access, isotope supply, and standardized protocols. However, PSMA-based theragnostics represents a paradigm shift toward individualized, biology-driven cancer care, setting the benchmark for future theragnostic developments across oncology.