Single-lesion Prostate-specific Membrane Antigen Protein Expression (PSMA) and Response to [(177)Lu]-PSMA-ligand Therapy in Patients with Castration-resistant Prostate Cancer

Initial reports of a clinical response in patients treated with the radioligand [(177)Lu]-PSMA-617 for castration-resistant prostate cancer (CRPC) are promising, despite known inter- and intrapatient heterogeneity. In metastatic CRPC, we examined the association of baseline immunohistochemical (IHC) expression of prostate-specific membrane antigen (PSMA) in a single lesion and responsiveness to [(177)Lu]-PSMA-617 therapy, measured as the PSMA maximum standardized uptake value (SUV(max)). Between 2015 and 2020, 19 patients with multiple metastases underwent single-lesion biopsy, [(68)Ga]-PSMA positron emission tomography (PET) imaging, and treatment with [(177)Lu]-PSMA-617. A monoclonal anti-PSMA antibody was used to semiquantitatively assess PSMA IHC in the biopsy specimen. Imaging evaluation of the biopsied single lesion and overall response was performed according to Positron Emission Tomography Response Criteria in Solid Tumors. The PSMA IHC histoscore correlated positively with pretreatment same-site PSMA SUV(max) (r(s) = 0.6). Nine patients had imaging after three cycles of [(177)Lu]-PSMA-617 and were included in the lesion-specific analysis. Of these, five patients (55.6%) had an SUV(max) response at the biopsy site, but three experienced overall progression. The histoscore was unable to predict the lesion-specific change in SUV(max) (95% confidence interval [CI] −44.2 to 69.2) or PSA (95% CI−125.2 to 17.2). There was no correlation between single-lesion SUV(max) and overall progression (r(s) = 0.1) on [(68)Ga]-PSMA PET imaging. Additional studies need to interrogate the clinical consequence of PSMA expression heterogeneity in metastases and the association with response to [(177)Lu]-PSMA-671. PATIENT SUMMARY: Treatment with a radioactive binding molecule called [(177)Lu]-PSMA-617 for men with prostate cancer resistant to castration (CRPC) is showing promise. We investigated the association between the presence of PSMA protein in metastatic lesions at biopsy and response to [(177)Lu]-PSMA-617 among men with metastatic CRPC. We found that assessment of PSMA presence at biopsy is not a reliable predictor of response to [(177)Lu]-PSMA-617. Additional studies are needed to better determine which CRPC metastatic sites will respond to this therapy.