Good morning, and welcome to the Lantheus third quarter 2022 conference call. This is your operator for today's call. Please note that all lines have been placed on mute to prevent any background noise. This call is being recorded for replay purposes. A replay of the webcast will be available in the investors section of the company's website approximately two hours after the completion of the call and will be archived for at least 30 days. I'll now turn the call over to our host for today, Mr. Mark Kinarney, Vice President of Investor Relations. Mark.
Thank you and good morning. Welcome to Lantheus's third quarter 2022 conference call. With me on today's call are Mary Anne Heino, our President and CEO, Bob Marshall, our Chief Financial Officer, and Paul Blanchfield, our Chief Operating Officer. Mary Anne will begin the call with introductory remarks and then turn the call over to Paul for an operational update. Bob will cover our financial results and updated guidance. Then we will open the call for Q&A, and finally, Mary Anne will provide closing remarks. This morning, we issued a press release, which was furnished to the Securities and Exchange Commission under Form 8-K, released in the investors section of our website at lantheus.com. For those of you not on the webcast, you can find the slide presentation in the investors section of our website under the Presentations tab.
Before we get started, I would like to remind you that our comments during this call will include forward-looking statements. Actual results may differ materially from those indicated by forward-looking statements due to a variety of risks and uncertainties. Please note that we assume no obligation to update these forward-looking statements except as required by applicable law, even if actual results or future expectations change materially. Please refer to our SEC filings for a detailed discussion of these risks and uncertainties. Also, discussions during this call will include certain non-GAAP financial measures. Reconciliation of these measures to the most directly comparable GAAP financial measures is also included in the investor section of our website. With that, it's my pleasure to now turn the call over to Mary Anne.
Thank you, Mark, and good morning to everyone joining us. We delivered an exceptional third quarter as we continue to find, fight, and follow disease to deliver better patient outcomes. Our strategy to accelerate growth and diversify our portfolio and revenue streams, which we outlined at the beginning of this year, is succeeding. I am pleased to note we reported revenue of $239.3 million, up more than 134% year-over-year. I'll take a few minutes now to highlight some of our recent progress across our portfolio. Almost 18 months into our launch, we are thrilled that PYLARIFY is firmly established as the leading PSMA PET imaging agent. We are particularly proud of the difference it is making for the U.S. prostate cancer community.
With commanding market leadership and continued growth of the overall market, our business has continued to grow even amidst increasing competition. We believe we will see continued growth as more patients and healthcare professionals become aware of the benefits of PSMA PET imaging and PYLARIFY in particular. Since our last call, we further expanded our U.S. footprint with additional sites activated for our PET manufacturing facility or PMF partners, increasing our overall capacity and adding redundancy. Our European partner, Curium, is making progress with their efforts to bring our product to market as the first commercially available F-18-based PSMA PET imaging agent in Europe, having filed their marketing authorization application with the European Medicines Agency in June. Last month, Curium presented top-line results from their pivotal phase III PYTHON clinical trial at the European Association of Nuclear Medicine or EANM.
The trial enrolled prostate cancer patients with biochemical recurrence who underwent definitive radical prostatectomy, external beam radiotherapy or brachytherapy. The clinical trial results highlighted that piflufolastat F 18 showed a significantly higher detection rate as compared with 18F-fluorocholine and had a higher impact on intended patient management. We're excited that we are one step closer to our leading U.S. F-18-based PSMA PET imaging agent, making a difference to the European prostate cancer community. We were also in attendance at EANM with several presentations on aPROMISE, which is branded as PYLARIFY AI in the US. Of note, in a top-rated oral presentation, we reviewed the results from a retrospective analysis using aPROMISE to evaluate PSMA PET CT scans pre and post-androgen deprivation therapy of men with treatment-naive, castrate-sensitive prostate cancer.
The results demonstrated that a change in automated PSMA scores in bone and lymph nodes is strongly associated with PSA response. The analysis also indicated that a quantitative automated PSMA score may assess treatment response in bone, which is not feasible with conventional imaging. We are pleased to share that we signed an agreement with Siemens Healthineers to integrate aPROMISE into the latest software for the company's workstations in the US and Europe. Through this collaboration, along with our collaboration with GE Healthcare that we announced earlier this year, our AI technology can be broadly distributed and integrated into the leading workstation systems that facilitate the nuclear medicine clinical workflow across the majority of PET sites in the U.S. and Europe. Switching now to our microbubble portfolio.
In our 22nd year since launch, I am proud to say DEFINITY remains the most chosen, most studied, and most trusted diagnostic ultrasound enhancing agent in the U.S. We have continued to grow our franchise and are sustaining our 80%+ share of the market. With respect to a key partnership, in September, GE Healthcare, our partner for the product candidate flurpiridaz, announced that the AURORA phase III pivotal trial met its co-primary endpoints for both sensitivity and specificity for detecting coronary artery disease or CAD, the most common form of heart disease and the leading cause of death globally. The trial also met its key secondary endpoint, demonstrating higher diagnostic efficacy for flurpiridaz PET as compared with SPECT myocardial perfusion imaging, or MPI, the predominant procedure used in nuclear cardiology today. In the U.S., there are approximately six million MPI procedures performed each year.
The phase III open label study, which enrolled over 600 patients across sites in the US, Europe and Canada, assessed the diagnostic efficacy of flurpiridaz in detecting CAD with invasive coronary angiography as the standard of truth. If flurpiridaz is approved, given the advantages of the F-18 isotope, this product would have broadly available distribution and also be suitable for exercise stress testing, which is challenging with the currently available cardiac PET radiotracer. Under the terms of our agreement with GE Healthcare, we are eligible to receive up to $60 million in regulatory and sales milestone payments, tiered double-digit royalties on U.S. Sales, and mid-single digit royalties on sales outside the U.S.. Now, let me turn the call over to Paul for an operational update on our business.
Good morning, everyone. As Mary Anne noted, we continued to execute on our strategy during the quarter, specifically for PYLARIFY and DEFINITY, which I'll highlight now. I'm pleased to announce that PYLARIFY, the U.S. market leader in PSMA-targeted PET imaging, generated net sales of $143.8 million and was used in over 30,000 patient scans during the quarter. Our success derives from significant unmet need, innovation, and execution. Prostate cancer is one of the leading causes of death for men, and conventional imaging does not offer sufficient sensitivity or specificity to adequately identify metastatic disease. PYLARIFY's innovation is its ability as a PSMA PET imaging agent to selectively bind to prostate cancer cells. In fact, PSMA binds to over 90% of prostate cancer cells, which in turn allows physicians to identify the location and extent of disease.
In our clinical trial, two-thirds of men had a change in their intended treatment plan based on their PYLARIFY image, demonstrating that these new insights are actionable by HCPs. Finally, execution since we acquired Progenics. The team successfully gained FDA priority review, which accelerated our time to approval and secured widespread reimbursement, established manufacturing and distribution capabilities at scale, built a commercial infrastructure to support a best-in-class launch that has already impacted the lives of over 90,000 men to date. Since the beginning of the third quarter, we further expanded PYLARIFY's U.S. footprint with new PMFs, including the first academic PMF to self-supply PYLARIFY, increased capacity at existing sites, added redundancy in key geographic areas, broadened our customer base, and made progress with PYLARIFY AI. Our new PMFs include Somerset, New Jersey, Nashville, Denver, Birmingham, and most recently, Davenport, Iowa, and Salt Lake City.
These new PMFs enhance our capacity in the New York City metro area and Tennessee markets and expand our footprint into Colorado, Alabama and now Iowa and Utah. We have now successfully served patients in 46 of the 48 contiguous states and the District of Columbia. As I mentioned last quarter, we modified our existing agreement with a key PMF partner to double the number of their PMF locations manufacturing PYLARIFY and extend the agreement to 2027. By the end of 2023, we expect our existing PMF network to increase by over 50%, further enhancing capacity and redundancy. In turn, our customer base continues to grow. We have been pleased with the rate of adoption and note that more than 1,000 customers have now ordered PYLARIFY, with 97% of them being repeat customers.
Our promotional efforts are increasingly focused on ensuring that referring HCPs, namely urologists, medical oncologists, and radiation oncologists, are aware of the benefits that PYLARIFY can offer the US prostate cancer community. In market access, we continue to make progress and are pleased that now five of seven Medicare administrative contractors or MACs have confirmed an agnostic approach to patient selection for PSMA-targeted radioligand therapy such as Pluvicto, meaning any approved PSMA PET agent, including PYLARIFY, can be used. We established a European collaboration with Curium for the commercialization of aPROMISE as they anticipate approval for piflufolastat F 18 in Europe in mid-2023. Turning now to DEFINITY, the market-leading ultrasound enhancing agent. Sales for the third quarter were $60.7 million, up 5.4% from the prior year period.
We continue to grow the franchise and maintain market leadership even amid staffing challenges and a decrease in referring physician patient visits that continues to impact the broader healthcare market, including echocardiography. I'll now turn it over to Bob.
Thank you, Paul, and good morning, everyone. I will provide highlights of the third quarter financials, focusing on adjusted results unless otherwise noted. Turning to the quarter, revenue for the third quarter was $239.3 million, an increase of 134.4% over the prior year period. Earnings per share for the third quarter was $0.99, an increase of approximately $0.91 over the prior year. Now we'll turn to the details, beginning with precision diagnostics. Revenue of $89 million increased 1.3% over the prior year quarter. Sales of DEFINITY, net of rebates and allowances, were $60.7 million, 5.4% higher as compared to the prior year quarter and in line with prior expectations for the third quarter.
TechneLite net revenue was $22.1 million, down 2.6% or about $590,000 from the prior year, and included a modest amount of opportunistic sales as guided on our last earnings call. I would like to note we have exited our thallium and gallium businesses effective at the end of the third quarter as capital expenditures necessary to keep our facilities current do not meet our internal return hurdle metrics given the declining market opportunity for these two products. Year to date sales totaled approximately $2.3 million and have been reported within other precision diagnostics. Radiopharmaceutical oncology contributed $144.7 million of sales, up significantly due to the exceptional performance of PYLARIFY. This result also includes an incremental contribution from AZEDRA.
Lastly, strategic partnerships and other revenue was $5.6 million in the quarter. Gross profit margin for the third quarter was 66.2%, an increase of 16.1% over the third quarter of 2021 from 50.1%. As has been the case in recent quarters, the increase is due mainly to favorable product mix led by PYLARIFY and DEFINITY, offset in part by expenses associated with expanding our PMF partner network for increased redundancy and capacity for PYLARIFY. Operating expenses were 16.7% favorable, from 40.2% in the prior year to 23.4% of net revenue in the current quarter.
Overall, operating expenses are in line with our expectations with continued focus on driving PYLARIFY awareness among the referring physician community, increased in-person commercial activities in support of commercial products and attendance at congresses, as well as focused investment in business development activities and our ERP program. As a note, we expect to transition our ERP program from a discovery phase to implementation beginning now in the fourth quarter, among other investments, which we expect will incrementally add to our current OpEx run rate. Operating profit for the quarter was $102.2 million, or an increase of $92 million or 904.1% over the same period prior year. Total adjustments in the quarter were $16.5 million before taxes.
Of this amount, $8.1 million and $8.3 million of expense is associated with non-cash stock and incentive plans and acquired intangible amortization, respectively. The remainder is related to net changes in our contingent receivables and liabilities, as well as acquisition, integration, and other non-recurring expenses. Our effective tax rate was 29% in the quarter. This rate includes a higher blended state tax provision rate due to PYLARIFY's geographic mix, offset in part by the impact stemming from the resolution of certain of our state tax UTPs in the quarter. The resulting reported net income for the third quarter was $61.2 million and $70.7 million on an adjusted basis, an increase of $74.6 million and $65 million, respectively.
GAAP fully diluted earnings per share were $0.86 and $0.99 on an adjusted basis, an increase from the prior year of $1.06 and $0.91, respectively. Now turning to cash flow. Third quarter operating cash flow totaled $93.6 million as compared to $4.3 million in Q3 of 2021. Capital expenditures totaled $6.1 million, up $3.7 million over the prior year quarter. Free cash flow, which we define as operating cash flow less capital expenditures, was a record $87.5 million, an increase of $85.6 million over the prior year period. Year to date, free cash flows totaled $162.8 million. Cash and cash equivalents, net of restricted cash, now stand at $257.3 million.
We continue to have access to our $200 million undrawn bank revolver and are comfortable with our strong liquidity position. Turning now to our updated guidance for the full year and Q4. We now forecast full year revenue to be in a range of $915 million-$919 million from the prior range of $885 million-$905 million. This implies a fourth quarter range of $243 million-$247 million.
As a reminder, this updated full-year range includes the recognized revenue from Novartis of $24 million, which was recorded in the first quarter. Turning now to earnings and keeping with the fourth quarter, adjusted EPS should be in a range of $0.95-$0.98. Taken together with the increased revenue expectation and year-to-date earnings performance, we are raising our full year adjusted EPS to be in a range of $3.80-$3.83 per share versus the prior range of $3.50-$3.60. With that, Mary Anne, Paul, and I will now take your questions. Operator, please go ahead.
Thank you. At this time, we will conduct a question-and-answer session. As a reminder, to ask a question, you will need to press star one one on your telephone keypad and wait for your name to be announced. Please stand by while I prompt the first questioner. One moment, please. Our first question comes from the line of Roanna Ruiz with SVB Securities. Roanna, go ahead, please.
Great. Thanks. Morning, everyone.
Good morning.
Good morning. I had a quick question about your over 1,000 customers who are ordering PYLARIFY. Maybe could you just elaborate a bit on what the breakdown is between large institutions versus smaller imaging clinics? Just curious how that demographic is evolving over time for PYLARIFY.
Yeah, I can take that. Thank you for the question. Of the thousand customers that have ordered to date, we've certainly seen a mix of what that looks like. I think historically when we look at the concentration overall of our business, it remains somewhat comparable. While many are familiar with the 80/20 rule, where 80% of business is driven by 20% of accounts, we actually have a broader usage across our business. 80% of our business is within about 35% of our accounts, and those larger accounts are a mix of large academic hospitals, freestanding imaging centers, as well as government facilities.
The overall breakdown across hospitals, across government facilities, and independent imaging centers has stayed relatively stable as we've continued to add imaging centers over time. I think I would add, as I've mentioned in the past, where we have certainly added customers from an imaging center perspective, going from 300 roughly at the end of last year to 900 at the end of the second quarter, and we're now at 1,000. The future growth, as we've said in the past, will increasingly come from activating the referring physician community, specifically urologists, medical oncologists, and radiation oncologists, to raise awareness of PSMA PET imaging and PYLARIFY specifically.
Got it. Super helpful. You sort of started to answer my next question. I was curious, how are you thinking about the future growth trajectory of PYLARIFY, like, going into 2023? Anything to expect as you start to see get more of a sense of how PYLARIFY growth goes, year- over- year?
Well, I think first and foremost, we're obviously incredibly pleased with the impact that PYLARIFY has had on the U.S. prostate cancer community. We take great pride in 90,000 patients having been scanned since launch. That impact, we think, can continue to grow. There is still significant room to be able to educate additional referring physicians on the benefits that PYLARIFY and PSMA PET imaging can bring to their customer base. There are still imaging centers to add, though we don't expect that number to increase at the same rate as we've seen in the past. Overall, we're incredibly excited about where we've gone to date and even more so at the potential to continue to bring PYLARIFY to the U.S. prostate cancer community in the future.
Interesting. Yeah, super helpful. Last question from me. I know you have a new competitive entrant in the market. I'm curious if anecdotally your field force is hearing anything in terms of competitive dynamics or in terms of strategies that you might use to protect PYLARIFY?
Roanna, I'll start there, and then Paul can jump in and Bob as well. We are very comfortable with our position as the most chosen and the leading PSMA PET imaging agent. We absolutely expect that to continue. We're not in protective mode with our business, we're in growth mode, and so we continue to open, and as Paul alluded to, there is demand to be unlocked among the physicians who generates requests for these exams, community, and that's where we will stay focused. As a market, we continue to see this market becoming larger and larger as physicians understand how they want to embrace PYLARIFY for utilization.
We're fully in growth mode and don't feel that it would be any way to define our kind of strategy at this time or our operations as being protective. Paul, do you wanna add?
Yeah. Yeah, Mary Anne, I think that's 100% accurate. I mean, I think we're incredibly excited with the growth, not only of PYLARIFY but of the overall market. If we look at, you know, what our competitor has published for their sales in the second quarter combined with ours, the market on an annualized basis was north of $500 million. With our third quarter results and what we've seen from them, the annualized market for PSMA PET imaging in the U.S. is already now over $700 million, just one quarter later. As Mary Anne mentioned, we are absolutely in growth mode. We have expected competition from the very beginning. We think overall it has helped raise awareness across the marketplace of PSMA PET imaging and the role this can play in the prostate cancer community.
You know, we've obviously been very pleased with our results, but also recognize that there is a role for competition. They have had some success specifically in geographies where we are still ramping up capacity and redundancy. There are some centers that have their own gallium generators that are gonna wanna provide self-supply, which is entirely appropriate. Then there's also customers that are gonna want dual supply. Unlike a small molecule or a biological area, this product is made on a daily basis across the country. We've also seen that. We are really focused on growing the overall market and are incredibly pleased, not only with the impact we've had on the community to date, but where we see going forward to continue to have that ability to grow this franchise.
That's good. Thanks for the clarification.
Our next question comes from the line of Larry Solow with CJS Securities. Larry, please stand by while I open up your line.
Just quick question to follow up on the PYLARIFY. Can you maybe just any color on? I think you said you went from 900 customers to 1,000. Usage, I'm sure ranges varying degrees, but I assume in terms of the doctors and clinics that have penetrated or that are using it, there's still a lot of room for growth in terms of within those clinics. Is that a fair statement?
Good morning, Larry. This is Mary Anne. I'll start, and then I'm gonna turn over to Paul. I think it's very fair to say that current utilization of PYLARIFY reflects the communities and how prostate cancer is treated. I think Paul was trying to describe that as well in talking about the mix of our customers and where they exist. We exist everywhere where prostate cancer is being treated. As you mentioned, we are still at the what will be the beginning, I'd say, of what full utilization will be as physicians not only gain access and familiarity with the product, but then also decide themselves how they want to embrace this product so for better management of prostate cancer disease.
Yeah, no. Larry, I think the question is fundamentally, you know, we are still incredibly excited at the growth prospects of PYLARIFY. There are only so many centers in the U.S. with PET CT centers. We've seen that number that have been using PYLARIFY grow, as we've mentioned, from 300 to now 1,000. But that number isn't gonna continue to grow at the same rates we've seen. We've penetrated the vast majority of imaging centers across the country that now have access to and are ordering PYLARIFY. Where the growth will come from is now activating those urologists and medical oncologists and radiation oncologists that were not early adopters to help them understand the benefits of prescribing PYLARIFY for those patients, and then those referring physicians in turn request scans from their imaging centers.
We're still very excited at the potential. We still think there's significant room for opportunity and for growth to reach a significant number of patients that are still not receiving PSMA PET scans. The growth is gonna come from all-
Everyone, we just had a significant echo feedback on our lines. I apologize if that was also translated to all of our participants, but it seems to have quieted now. Paul was just completing his comments talking about the growth in the future for PYLARIFY, which will also come from activating more patient pools as we engage with those physicians who are generating demand currently for imaging done with conventional approaches, which we believe will translate over to PSMA PET-based imaging.
Great. Just a quick follow-up, just Mary Anne, on the pass-through status. I think it's set to expire at the end of 2024. Can you just, you know, I think I know this came up at your Analyst Day too, but can you just give us a couple minutes to discuss that and your confidence that it won't necessarily impact pricing, you know, once that expires?
Absolutely, Larry. As you correctly noted, pass-through status under the current administration will end at the end of 2024 for PYLARIFY, having been in place for three years. The piece that we are educating as well as we can to our audience about pass-through is understanding for what sites of care and what patient pools pass-through applies. Pass-through is only an administered benefit, you know, the pricing schema for traditional Medicare patients treated in the hospital outpatient setting. What we continue to see is migration of imaging out of the hospital outpatient center and a decreasing pool of patients who are insured under the traditional Medicare benefit.
Both of those factors, especially in combination, result in a smaller pool of patients who would be covered by pass-through, especially as we get out to the end of 2024. Now, we also believe that the physician adoption of PYLARIFY and physician satisfaction with the results they're seeing with our images will also create, I'll call it a stickiness, or we could call it a, you know, product loyalty to PYLARIFY even in a post pass-through period. Finally, we still are very carefully monitoring a piece of legislation called the FIND Act, which the purpose of is to eliminate what is currently the pass-through pricing scheme for radiopharmaceuticals and certain other products.
Here we're specific to radiopharmaceuticals, which means that we would have permanent, I'll say, what we would say is more fair reimbursement levels for complex radiopharmaceuticals. Paul, do you wanna add anything?
No, I think it's very well said, Mary Anne.
Great. Thanks so much. Just last question, just for Bob real quick. Just on the operating expenses, looks like, you know, it kind of trended down sequentially. Was there anything timing related there as G&A was a little lower, R&D a little lower, or is that just sort of, you know, moving around from quarter to quarter?
It's just moving around a little bit quarter to quarter, Larry. If I just look, you know, sequentially, it's pretty much in line on an average basis. You do get puts and takes during the year. I'm trying to signal those for the fourth quarter, particularly when I think about our ERP program. You know, there are certain operating expenses associated with getting that program off the ground. We've been doing a lot of discovery work, and that implementation, you know, phasing starts now here in the fourth quarter. I do expect it to be incrementally higher. I don't mean, you know, tens of millions. I'm talking, you know, small numbers.
We are also using this opportunity to, you know, do advanced work in sales and marketing, if you will, around market research, as we know, as we really kinda dive into, you know, the different markets in which we're playing, particularly in the prostate cancer arena. Thanks for the question.
Great. I appreciate all the color. Thank you.
Our next question will come from the line of Mr. Anthony Petrone with Mizuho Group. Anthony, will you please stand by while I open up your line? Anthony?
Hello?
Yes.
Uh-
Your line should be open.
Okay, great. Thank you. Going back to a couple on PYLARIFY, stayed on the 1,000 sites at the end of 3Q, you know, across 46 states. Just wondering, Paul, when we think about the actual number of sites out there in the United States, you know, what is that number? Are we kind of at the upper bound just in terms of sites? When you think about penetration into the sites, certainly the growth going forward would be, you know, getting additional physicians, you know, trained and prescribing PYLARIFY. When you think about the penetration level at sites on a physician level, where is that number on average across the 1,000? I'll have a couple of follow-ups.
Yeah. Thanks for the question. I think when we think of the total number of sites, IMV is probably the best source, you know, to kinda look to. I will note that the number is not exact because many centers around the country have mobile sites that may have a mobile camera, you know, one or two days a week. When you think of kind of full cameras on an annualized basis, you know, anywhere in that 2,000 ± range. I think we've naturally focused on the big centers. When we think about growth from 1,000, we think that number will continue to grow, but at a decreasing rate. There are certainly PET CT centers in geographies where we are still to open additional PMFs.
You know, if you refer to pylarify.com, you can see where our PMF coverage is. We still do have some areas to build in as we add additional capacity across the country in those areas, and those are where we'd really add PET CT centers. To your point, the bulk of the growth is going to come from driving more volume through those existing centers, and that comes from activating the urologists and oncologists that are not early adopters, that have not been excited for years in expecting PSMA PET imaging. As an example, in urology, the initial staging indication, we were the first commercial PET agent in prostate to have that indication. That's a market we're still very much building. PET agents were not necessarily used in that space before.
Your community urologists, your large urology group practices, there's still a tremendous amount of education to have there to be able to activate them to ensure that all appropriate candidates are being prescribed PYLARIFY. We haven't put a number on it, but we're incredibly excited for the future and see continued growth for PYLARIFY as we continue to activate those marketplaces.
Just to follow up on competition, you know, Blue Earth Diagnostics out there with the SPOTLIGHT results at ASTRO and seems a little bit more comparable, you know, than a Gallium-68, you know, PSMA PET imaging agent. Just wondering how you think the competitive dynamic shifts when we have a similar agent come on market. Any thoughts there? Then again, the last one for me, I just wanna throw one in on F-18 with GE. Maybe just a reminder on the total available market statistics that are out there for flurpiridaz F 18, and how you think that market proceeds in 2023. Thanks.
Good morning, Anthony. It's Mary Anne. I'll speak a little bit to your questions, and then anyone else here can jump in if they want to add additional color. This goes back, I think, to a question we've already taken this morning that was suggested we might be, like, moving into protective mode. We remain firmly established in growing this market. As a market leader, it's almost an obligation. I think you've seen the same behavior from us with DEFINITY over the years, and that is going to remain our focus. Even amidst competition. You're right, the entry of a second F-18-based product would be, I guess, a closer parallel to PYLARIFY.
We are very confident that especially with the PMF networks that we've set up, that PYLARIFY will remain the market-leading and commanding leader in this PSMA-based market, and that will be true after the introduction of another F-18-based PSMA PET imaging agent. To flurpiridaz and to their kind of our relationship with GE Healthcare, the market that we look at there is a market that we know very well, and that, as I mentioned, is the MPI market. This is the standard of care imaging for coronary artery disease in the United States healthcare market now. On an annual basis, about 6.1 million procedures that are done. I will make an analogy here to what we've seen happen with PSMA-based PET imaging with the availability of PYLARIFY.
First the two academic products and then, and closely after, PYLARIFY. We've seen, I think it's fair to say, a wholesale switch from what is used as standard of care imaging for prostate cancer. The part of that is the incredible, specificity, sensitivity, and just clarity of the images that can be produced with the combination of an F-18 isotope and then the modality of PET imaging. The same is true with cardiac imaging. Currently, and we've been in this market for over 40 years, cardiac imaging is done with SPECT-based modality. The switch to F-18, an F-18-based product with flurpiridaz, the clarity of images, we used to describe it as moving from black and white TV to HD or high definition, high-def TV. There's just that much more clarity and specificity and sensitivity with the images.
We very much look forward to our partner, GE is our partner who will take the lead on that, bringing that awareness into the market once the product is approved. We're confident that we will see physicians embrace that product in a similar fashion to what we've seen with PSMA-based PET imaging.
Maybe [crosstalk] I'll just add a bit more. Maybe I'll just add specifically on the Blue Earth and really F-18 competition. You know, and as I think as Mary and I have both said, you know, greater voice and awareness around PSMA PET imaging will help grow the overall market. We've seen this grow. Already we mentioned from a combined annualized north of $500 million in 2Q to now north of $700 million in 3Q. We're incredibly excited to continue to grow that overall market. I think you're right to note that they've published data on one of their clinical trials. We have not yet seen data on the other trial. But you know, regardless of how that plays out, we do think there's a significant first-mover advantage.
The progress we've made in contracting with now 1,000 sites using PYLARIFY, the significant progress we've made on market access, including pass-through and coverage, when we think of all those pieces put in place, as a first-mover advantage. I would also note our PMF network is already up and is active. We have contracts through some of the major players through 2027 with preferred cyclotron status making F-18. We feel well positioned to continue to be the market leader in what is an ever-growing PSMA market with many more patients left to scan going forward. We're incredibly excited.
I'll hop back in queue. Thanks.
Our next question comes from the line of Mr. Richard Newitter with Truist. Please stand by while I open up his line. For him to pose his questions. Please stand by. Mr. Richard Newitter of Truist, your line should be open.
Hi, thanks for taking the questions. I'm not sure if I missed it. Did you guys give specific PYLARIFY guidance, or update the range there? If so, could you provide that?
Richard, we did not give specific, but I mean, it is implied when you do the math around, you know, around the guidance that I did give. In the prior guidance range, I think we had implied a full year range of about $480 million-$500 million. Now that range is now sort of in the $500 million. You know, and I have refined it, you know, there are eight weeks to go in the year, if you will, to sort of a $513 million-$516 million type range for the full year, which then gives you a Q4 number in the, you know, sort of right around bracketing about $150 million, if you will.
Q4?
For 4Q.
Yeah. Okay. I guess you know you're talking about all this capacity coming online and you know you have a bigger user base. I guess you know it seems like that sequential improvement is you know it's not huge but I guess you know how should we think about that? You know and then secondly on that topic you've talked in the past about getting to capacity for PYLARIFY exiting 2022 I think in the 150,000-200,000 dose range. Where are you from ramping up to that level currently? Where do you think you'll be exiting 2022? And is there any reason to think that every you know every unit you can produce right now isn't you know isn't getting used? In other words is demand continuing to outstrip supply?
Thanks.
Richard, I'll start there, and then Paul can jump in with some more specific numbers. To your very last comment/question about, you know, our comfort level that every dose is getting used. Just as a reminder, this is a batch manufactured product, and so it is possible that you have in certain more, I would say, more rural geographies, where they're producing a full batch as they do with F-18 to make the product, but they don't have what can optimally be produced with a batch, which could be 20+ doses, the demand for that in that given day. That is part of our economics and already built into our assumptions and has been. As we
To your other point, as we continue to ramp up, we are really now from a capacity perspective, we're thrilled with the rollout plan we've had, but there are areas where we continue to add especially redundancy, some capacity and then redundancy, because these are very large geographic markets. Paul mentioned the sites that we opened recently was in the greater New York area. That is an area where we continue to see the opportunity to service more demand with additional capacity or redundancy, whichever we wanna call it. Paul, do you wanna add in?
Yeah, no. Thanks, Mary Anne. I think to go into your question, you know, for overall capacity and redundancy, we continue to increase this, right? We noted the new PMF regions, Colorado, Alabama, Utah, and Iowa, since the end of the second quarter, we've added. Now, we've served patients and sites in those markets, but we've been bringing in doses. It's obviously better for customers, it's better for patients to be able to have local manufacturing there. It provides more flexibility, not only in terms of the number of doses that we can bring in, but the time that we can bring doses in to meet the workflow needs of the PET CT centers. As Mary Anne mentioned, we've been building redundancy, in places like New York City metro area and in Tennessee.
We've also invested in the existing sites since we've been continuing to add Trasis boxes. There are PMFs that now have multiple cyclotrons, and we're able to now run multiple batches over the course of the day to truly meet the needs of the customer base. When we think about the overall capacity, you're right, we highlighted about 150,000-200,000. I would note that on an annualized basis, we're gonna be ahead of that, by the end of the year based on the capacity and the redundancy. The national number, I don't wanna call it irrelevant, but, right, it very much matters on a local market. There are markets where we still need to build capacity and the redundancy in there to meet medical practice and how it's evolving.
We also need to ensure that we continue to grow because we're incredibly excited about the future. Does that help?
Yes. Yes, it does. Just maybe the underlying assumptions in the implied 4Q ramp.
The underlying assumption around demand? Richard, can you just clarify your question?
You have an implied guide of 150. Maybe just talk to us a little bit about how you arrived at that. Why is that the right number? You know, you historically guided sequentially, you know, flat to up slightly. I guess, is your approach to guidance any different? What are the key assumptions kind of to get to that level EPS?
I would say our approach to guidance remains consistent. I think that's something we've established as a company as to kinda how we choose to communicate on a forward basis. I would also say we're still in a launch. I know it feels like now we've been talking about PYLARIFY for a long time, but we are still in a launch. I think our numbers are. You could say we continue to be slightly conservative because we're still not fully aware of how large the intent is with the medical community to embrace PYLARIFY across the entire disease spectrum of prostate cancer.
That continues to be an opportunity for us that we work on from a demand generation perspective within our labeled indications, but we also note what the medical community is choosing to do with these products. That's something that Paul has some very specific research ongoing, market research ongoing, so we can better understand the community. Until we do, I think you'll continue to see this practice from us, which is to have a bracketed implied guidance. I would say operationally, you've seen us exceed on each of the quarters.
Rich, I would just also wanna point out that, you know, we are entering the peak time of the year within the quarter, you know, major holidays, and, you know, with the prior experience of last year where we did, I believe it was like $35 million, $36 million in the quarter last year. You know, this is the first year with a much more expanded network coming into that holiday season. We wanna make sure that we, you know, we fully understand how those dynamics work in that part of the year.
Thank you.
Our next question comes from the line of Matt Taylor. Matt, please stand by while I open your line up for you to pose your question. Mr. Matt Taylor with Jefferies, your line is open.
Thank you. Can you hear me okay?
Yes, sir.
Great. Hey, everybody. I wanted to follow up on. Good morning, Bob. Two things. One is, you know, when you think about the next couple of years, I know this is kind of an unprecedented launch, you know, maybe you could talk about what you think market growth could be and your ability to grow within that framework, you know, given some of the advantages that you have, the first move or setting up this network, et cetera, as you see more competition come online. Could you give us any high level thoughts on that?
Matt, you know, obviously we understand that people are interested in, you know, how the next year looks, as we kind of get to the end parts of this year. You know, as we think about 2023, 2024, we certainly expect healthy growth for the business in its totality, and certainly from the contributions that we expect to get from our leading products in PYLARIFY and DEFINITY. You know, as we think about how, you know, models that we see from a street perspective look, we're comfortable that we're going to be able to continue to grow this business, do so profitably, and see our free cash flows.
You saw what we did here in the third quarter with a record free cash flow number of nearly $90 million. That's those kinds of numbers are going to continue to grow, and we're going to be able to you know really kind of strengthen the position of this company as we think you know into this you know the near term planning horizon that we're you know discussing.
I would just add, Matt, we're not here to offer annual guidance for 2023. However, if we look at the two major markets we're in now, as we've repeatedly kind of tried to offer here, we see significant continued growth in the PSMA imaging market, not only for the demand of generating that we've already generated for patients for initial staging and for recurrence, but also because of the continued, what will be the continued entrance of therapeutic agents into that market. On the other side, we didn't speak to this significantly today during the call, but DEFINITY, Paul, did offer that we've seen some, I'll say, softness in the total echocardiography market, which again, historically, we have never tried to influence the total number of echocardiography studies done in the United States medical market.
All of our point-of-care medical education has always been at the use, the addition of, an ultrasound enhancing agent to studies already underway. We have seen some softness in the total number of echocardiography studies based on what we see is decreased percentage of in-office visits in cardiology year- over- year, and then kind of continued impact of staffing challenges both at the nursing level and at the sonography tech level. If that heals itself coming into the coming year, then we would expect to see improved growth rates for DEFINITY, as a kind of a rebound from the increased number of echo studies and what will be the increased demand then for use of an ultrasound enhancing agent.
Mm-hmm. Thanks for the thoughts there. I did want to ask you one about how you mentioned the cash flow and certainly building a lot of cash. Can you talk about what you're thinking about doing with that strategically as you kind of pile more on here? What kind of things could you tuck into the portfolio that would be additive and synergistic? How do you think about acquisitions?
I'm just gonna start there quickly, Matt, because then it's obviously a question more for Bob. I'd like to say that as a company, we see ourselves, you talk about like what we could tuck into our portfolio. We see ourselves as a very highly chosen and attractive partner for, you know, companies out there that have assets that are looking for that type of relationship. I think what we've demonstrated already with the Progenics acquisition speaks to the kind of talent we have here and what we do with assets that are brought under our care.
Yeah. Certainly, you know, in my prepared remarks, I did make the comment that, you know, in terms of our OpEx, we are clearly visibly working hard to fill a pipeline of opportunities. If I just go back to our investor day in terms of what we are interested in doing, we are, you know, focused on late stage or near commercial stage assets that are high growth, high margin. But what those are likely to do are to leverage, you know, our commercial manufacturing supply chain, as you know, sort of our core capabilities as a company. We also want to make sure we can get robust diligence on these targets and the environments in which their products or product candidates are going to be working in.
From a financial perspective, obviously, we're looking to sustain double-digit growth long term. You know, those are the kinds of assets we're targeting and looking at to be able to drive that. We're gonna be able to maximize the opportunities to drive profitability, margin accretive, particularly as you think about, you know, how we have been able to sort of transform the company with the Progenics acquisition to, you know, to drive expanding gross margin and EBITDA type margins. Again, I think that we're going to really work hard to be able to achieve these types of criteria, filling out the metrics that are gonna help drive, like I said, long-term sustainable growth done profitably.
Thanks, Bob. I had one last one I just wanted to ask about. When you look at the dollars per customer this quarter. Basically the math would be you added 10% more customers, you did 10% more sales. That would imply same store sales didn't change very much. I don't know dynamics like seasonality or stocking, if those kind of things played in. Maybe you could talk about the expectations for same store sales going forward and where you think those could go.
Well, Matt, that is a new one. I've never seen same-store sales apply to radiopharmaceuticals before. Congratulations on being unique with your question. I think what this comes back to some of the conversation we've already had in the Q&A here, and that is the ability with this same store to bring in additional capacity and redundancy to better penetrate and service those markets. From that perspective, it's quite frankly. It's not something we calculate in the way that you've defined it. I think for having asked the question, we would say in the larger geographic areas, where again the patient concentration is, we will continue to see improvement in what you're referring to as same-store sales.
Yeah, Matt, maybe just some added color there, and totally understand the question. I think the key piece, and I'll go back to a bit of information I shared earlier, is that about 80% of our business comes from about 35% of our customer base. That core customer base hasn't materially changed in terms of the percentage. While we're adding new imaging centers, those are by and large, smaller imaging centers, smaller regional hospitals. The vast majority of large academic centers of significantly sized freestanding imaging centers are in place and have been in place. I think we're seeing continued growth and that the added imaging centers are not necessarily a key driver of growth. It really is the volume at existing sites.
That's what we're focused on continuing to grow in your PYLARIFY same-store sales, which I understand. You know, we're driving more same-store sales, if you will, by activating those referring physicians, and that's really gonna be driving future growth.
Okay, that makes sense. Thank you. Thank you very much.
You're welcome.
Our next call will come from the line of Justin Walsh with JonesTrading. Justin, please stand by as I open your line up for you to pose your question. Justin, your line should be open.
Hi, thanks for taking the question. It was great seeing PYLARIFY AI showcased at EANM. How would you characterize its reception at the meeting and maybe some feedback that you received from users as PYLARIFY has continued its rapid market penetration?
Justin, this is Mary Anne, and I'll take your question. We were thrilled with the reception at EANM, and we think this is very indicative of what's happening, practice of medicine and use of therapies where the mandate will continue to rise, that products that are used have these complementary products associated with them or offerings associated with them that further embellish and further improve the whatever we're gonna say is the efficacy of the products. In the case of PYLARIFY AI, this offers, you know, consistent quantification across the important body regions of PSMA imaging, and it augments what a physician reader can see and interpret on a screen. I think it's very much embraced as necessary and complementary, and we're doing everything we can to ensure that it's fully integrated.
You heard about the additional collaboration that we announced today, which complements the one we had already announced. What this makes is PYLARIFY AI essentially ubiquitous. It'll be already present in the workstations that are being used by nuclear medicine physicians and radiologists to read these images. We think that's an important trend that we are absolutely supporting. From adoption perspective, I think we also see what is typical, and that is these products and these additional pieces of software tend to be embraced first in research because that's where you really come to fully understand how the product will play into a clinical workflow.
We're really pleased also with the adoption rate we've seen across the major academic centers in the United States market, especially for research applications, which will then, we believe, lead to commercial adoption as well.
Our final question will come from the line of Yuan Zhi with B. Riley. Yuan, please stand by as I prompt you to open up your line. Yuan, your line is open.
Good morning. I guess I will be the first one today to say congrats on another strong quarter. Thank you for taking our question.
Thanks, Yuan.
First, have you heard any staffing shortage of radiology imaging technicians in the last quarter, which might have impacted the use of PYLARIFY in the quarter?
Yuan , I'll answer that question. The answer is, we have not anecdotally had that feedback, but this part of the market, which is PET/CT imaging centers, is not one that is as historically familiar to us as echocardiography suites. I think we have stronger insight into echocardiography because our relationships there have been in place for so long. I cannot affirm or deny whether there is any staffing shortages at PET/CT imaging centers. We know that among our PMF partners, we've seen very good response and very good support there to ensure that what they produce can be produced, that there's no staffing shortages there.
Got it. That's very helpful. Our second question is on the phase II clinical trial of NM-01, the PD-L1 imaging agent. You guys had the first patient dose in May. Just want to check, can you provide an update of the trial enrollment and maybe the timeline to have the top-line data there?
Yuan, at this time, I cannot offer an update on trial enrollment. We will speak to it as we hit significant milestones, but at this time, we are only publicly still having reported the first patient in, and I would anticipate it will be probably first quarter of 2023 when we next make an update on that trial.
That concludes our question and answer session. I will now turn the call back over to Mary Anne for her closing remarks.
Thank you everyone, for joining us on today's call. In closing, the third quarter was another strong one for our business as 2022 proves out to be a historic year for Lantheus. Building on more than 65 years of life-changing science, we continue to innovate to deliver on what matters for healthcare professionals and patients. I'm extremely proud of the results the Lantheus team has delivered. Their hard work, focus, and dedication to our patients and our corporate strategy are evident in the results we outlined today. As the year comes to a close, we continue to be driven by our purpose to find, fight, and follow disease to deliver better patient outcomes. Thanks, everyone.
This concludes the Lantheus third quarter earnings call. You may now disconnect.