68Ga- and 177Lu-Labeled PSMA I&T: Optimization of a PSMA-Targeted Theranostic Concept and First Proof-of-Concept Human Studies

On the basis of the high and consistent expression of prostate-specific membrane antigen (PSMA) in metastatic prostate cancer (PC), the goal of this study was the development, preclinical evaluation, and first proof-of-concept investigation of a PSMA inhibitor for imaging and therapy (PSMA I&T) for Ga-68-based PET and Lu-177-based endoradiotherapeutic treatment in patients with metastatic and castration-resistant disease. Methods: PSMA I&T was synthesized in a combined solid phase and solution chemistry strategy. The PSMA affinity of Ga-nat-/Lu-nat-PSMA I&T was determined in a competitive binding assay using LNCaP cells. Internalization kinetics of Ga-68- and Lu-177-PSMA I&T were investigated using the same cell line, and biodistribution studies were performed in LNCaP tumor bearing CD-1 nu/nu mice. Initial human PET imaging studies using Ga-68-PSMA I&T, as well as endoradiotherapeutic treatment of 2 patients with metastatic PC using Lu-177-PSMA I&T, were performed. Results: PSMA I&T and its cold gallium and lutetium analog revealed nanomolar affinity toward PSMA. The DOTAGA (1,4,7,10-tetraazacyclododecane-1-(glutamic acid)-4,7,10-triacetic acid) conjugate PSMA I&T allowed fast and high-yield labeling with Ga-68(III) and Lu-177(III). Uptake of Ga-68-/Lu-177-PSMA I&T in LNCaP tumor cells is highly efficient and PSMA-specific, as demonstrated by competition studies both in vitro and in vivo. Tumor targeting and tracer kinetics in vivo were fast, with the highest uptake in tumor xenografts and kidneys (both PSMA-specific). First-in-human Ga-68-PSMA I&T PET imaging allowed high-contrast detection of bone lesions, lymph node, and liver metastases. Endoradiotherapy with Lu-177-PSMA I&T in 2 patients was found to be effective and safe with no detectable side effects. Conclusion: Ga-68-PSMA I&T shows potential for high-contrast PET imaging of metastatic PC, whereas its Lu-177-labeled counterpart exhibits suitable targeting and retention characteristics for successful endoradiotherapeutic treatment. Prospective studies on larger cohorts of patients are warranted and planned.