Tumour Microenvironment-Informed Radiotheranostics: Why and How Nuclear Medicine Could Advance Precision Oncology in the Decade Ahead

Despite significant progress in targeted cancer therapies and conventional imaging methodologies, the effective detection and treatment of solid tumours remain a major clinical challenge. This is thought to be caused by the complexity and heterogeneity found in the tumour microenvironment (TME), which significantly effects drug delivery and therapeutic response. Different levels of fibrosis, varying immune-cell infiltration, and disorganized vasculature form barriers for therapeutic approaches. However, in the next decade, radiotheranostics, defined here as the combined use of matched diagnostic and therapeutic radiopharmaceuticals, could present a targeted and flexible strategy for addressing some of the challenges caused by the TME. By combining molecular imaging with therapeutic delivery, it enables the in vivo visualization of TME features and the selective treatment of tumour and stromal compartments. This provides the unique opportunity to target tumour regions resistant to conventional therapies, including those shaped by (extracellular matrix) ECM stiffness, immune infiltration, or hypoxia. However, new strategies are needed to identify targets and evaluate their efficacy for more precise therapies. In this review, we will discuss why radiotheranostics is an ideal field for advancing the therapeutic approaches to solid tumours by incorporating the growing understanding of the TME. We will discuss how key microenvironmental features affect radiotracer distribution and treatment outcomes. We will highlight emerging tools including ECM- and immune-targeted imaging, patient-derived organoids, and organ-on-chip models which will be instrumental in developing physiologically relevant radiopharmaceutical therapies. Finally, we will discuss how spatial/single-cell transcriptomic approaches can support target discovery and allow for patient outcome assessment, with the aim of integrating microenvironment-aware insights into the development of novel radiotheranostic agents.