Simple SummaryAdvanced prostate cancer can be treated with [177Lu]-Lutetium-PSMA radi-oligand therapy (Lu-PSMA) in advanced stages. However, little is known about the predictive factors for treatment success. We retrospectively analyzed Lu-PSMA radioligand treatments in 86 patients. The focus of the study was to describe clinical factors at baseline and during early treatment that are related to survival. In addition, imaging results from PSMA PET/CT-, laboratory values such as PSA-response, and safety and tolerability of the treatment were assessed. The observed side effects were comparable to previous studies and anemia was the most frequent adverse event. Pre-treatment hemoglobin level of ≥10 g/dL and a lower PSA values at treatment start were favorable factors for longer survival. The presence of visceral or liver metastases were not significantly associated with worse prognoses. With careful patient selection, an individualized Lu-PSMA treatment approach is feasible and patients with dose-limiting factors or visceral metastases should be included in prospective trials. This novel information can be helpful for therapeutic decision making.AbstractCastration resistant prostate cancer (CRPC) is characterized by an aggressive biological behavior with a relatively short survival time, especially in progressive tumors pretreated with new hormonal agents and taxane chemotherapy. [177Lu]-Lutetium-PSMA (Lu-PSMA) treatment has proven efficacy in these patients. However, around 30% of the CRPC patients do not benefit from Lu-PSMA treatment, and little is known about predictive factors for treatment success if Lu-PSMA is offered in an individualized approach based on clinical and laboratory features. In this monocentric retrospective study, 86 CRPC patients receiving Lu-PSMA treatment were evaluated. The focus of the study was to describe clinical factors at baseline and during early treatment that are related to overall survival (OS). In addition, PSMA PET/CT-, PSA-response, and safety and tolerability (CTCAE adverse event reporting) were assessed. Efficacy endpoints were calculated using stratified Kaplan–Meier methods and Cox regression models. Mean applied dose was 17.7 GBq (mean 5.3 ± 1.1 GBq per cycle) with an average of 3.6 (range 1–8) therapy cycles. Patients were followed up for a mean of 12.4 months (range 1–39). The median OS was 15 months (95% CI 12.8–17.2). The best overall response rate in patients assessed with PSMA PET/CT and PSA response was 27.9%, and 50.0% had at least stable disease. Nine patients had a ≥grade 3 adverse event with anemia being the most frequent adverse event. Positive predictors for prolonged OS from baseline parameters were pre-treatment hemoglobin level of ≥10 g/dL and a lower PSA values at treatment start, while the presence of visceral or liver metastases were not significantly associated with worse prognoses in this cohort. With careful patient selection, an individualized Lu-PSMA treatment approach is feasible and patients with dose-limiting factors or visceral metastases should be included in prospective trials.