• tRNA dysregulation in cancer encompasses altered expression, modifications, aminoacylation, tdRs, and trafficking, collectively reprogramming the oncoproteome.
• The tumor microenvironment actively shapes tRNA reprogramming to support adaptive survival, cancer stemness, and therapy resistance.
• Therapeutic strategies targeting tRNA mechanisms include suppressor tRNAs, tdRs, inhibitors of tRNA-modifying enzymes, and ARS inhibitors, with varying stages of development.
• This review systematically evaluates these approaches, highlighting safety considerations and future trajectories for clinical translation.