Lantheus Holdings, inc (LNTH) Q2 2021 Earnings Call Transcript

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Lantheus Holdings, inc (LNTH 1.24%)
Q2 2021 Earnings Call
Jul 28, 2021, 8:00 a.m. ET

Contents:

• Prepared Remarks
• Questions and Answers
• Call Participants

Prepared Remarks:

Operator

Good morning, ladies and gentlemen. Welcome to the Lantheus Holdings Second Quarter 2021 Financial Results Conference Call. This is your operator for today's call. [Operator Instructions] I will now turn the call over to your host for today, Mark Arne, Senior Director of Investor Relations. Mark?

Mark Kinarney -- Senior Director, Investor Relations

Thank you, and good morning. Welcome to the Lantheus Holdings Second Quarter 2021 Financial Results 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 Commercial Officer. Mary Anne will begin the call with introductory remarks and then turn the call over to Paul to give an update on the Polarity commercial launch. Mary Anne will return to give a business update, and then Bob will cover our financial results and updated guidance. Mary Anne will conclude the call with closing remarks, and then we will open the call for Q&A.

This morning, we issued a press release, which was furnished to the Securities and Exchange Commission under Form 8-K reporting our second quarter 2021 results. You can find the release 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. In particular, the impact of COVID-19 on our business results and outlook continues to be a best estimate based on currently available information.

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 the 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 Investors section of our website. With that, it is my pleasure to now turn the call over to Mary Anne.

Mary Anne Heino -- President and Chief Executive Officer

Thank you, Mark, and good morning to everyone joining us on today's call. I'm pleased to report that the second quarter was a successful and productive one. During the quarter, we announced the FDA approval and commenced the commercial launch of PYLARIFY, the first and only commercially available PSMA PET imaging agent for prostate cancer. DEFINITY performed well and has maintained its market leadership with more than 80% share of the U.S. ultrasound enhancing agent market. AZEDRA sales significantly increased as TechneLite delivered stable revenue sequentially. We are committed to building on this positive momentum and delivering value for shareholders.

Before I turn the call over to Paul for an update on our PYLARIFY launch, I would like to provide background on why we believe PYLARIFY is an important addition to the treatment of prostate cancer. On May 26, the FDA-approved polarity, a fluorine 18-labeled prostate-specific membrane antigen, or PSMA, targeted positron emission tomography or PET imaging agent. PYLARIFY identifies PSMA, the protein expressed on the surface of prostate cancer cells in men with suspected metastasis, who are candidates for initial definitive therapy and/or with suspected recurrence of prostate cancer. Slide seven highlights the time points where PYLARIFY received approval by the FDA.

Starting with the purple box, initial staging describes patients who are candidates for initial definitive therapy and are suspected to have metastasis. While approximately 248,000 men are diagnosed annually with prostate cancer, currently, we believe there are approximately 40,000 men in this category who may be eligible to PYLARIFY scans based on suspected metastasis. Second, as shown in the two blue boxes, there were approximately 105,000 and 25,000 men, respectively, who may have a suspected recurrence of prostate cancer as indicated by rising prostate-specific antigen, or PSA. These patients are also candidates for a PYLARIFY scan based on our awarded indication.

As you can see, overall, a prostate cancer patient's journey can last 15 years or more and is marked by frequent interactions with the physician to determine treatment course. We believe PYLARIFY offers a number of advantages as a diagnostic agent. First, it is a PET modality, which offers several advantages versus current conventional imaging modalities. PYLARIFY demonstrated a high detection rate of metastatic disease, even in patients with low PSA levels and was not limited by the size of lymph nodes with respect to detection of nodal disease and visualize metathesis which CT or bone scan could not, as was demonstrated in our Phase III CONDOR study. Another advantage to PYLARIFY is that it works by binding to PSMA, a protein that is over expressed on the surface of more than 90% of primary and metastatic prostate cancer cells.

This enables the reader of a PYLARIFY PET scan to detect the presence and location of prostate cancer cells with greater sensitivity versus imaging modalities that are not specific to PSMA. The third advantage is that PYLARIFY is radio labeled with F-18. The attributes of F-18 contributes a high-quality, clear, detailed and reproducible images for prostate cancer disease monitoring. Production of the F-18 isotope at PET manufacturing facilities, or PMS, offers high batch capacity and F-18's 110 minute half-life allows broad geographic distribution and clinical flexibility in administration. Finally, a distinct advantage of PYLARIFY will have is that the proprietary patent-protected artificial intelligent medical device software we have developed to assist physicians with the reading of PYLARIFY scans, aPROMISE in place deep learning to quantify and automate the reading of PYLARIFY images. aPROMISE is designed to provide enhanced consistency in quantitative analysis and precise anatomical context and can enable quantitative reporting.

Collectively, these benefits potentially contribute to increased reader efficiency and reproducibility of PSMA PET/CT image assessments. Importantly, for the manage of prostate cancer, the data from our studies demonstrated PYLARIFY is more likely than conventional imaging to detect the spread of disease, providing more accurate and potentially earlier detection of disease, which we believe will empower doctors, along with patients and their families to make more informed decisions about how to treat their prostate cancer. Based on the data from our clinical trials, we believe PYLARIFY may also have an important role in the clinical development of product candidates for prostate cancer treatment as an important biomarker. For these clinical applications, I will refer to PYLARIFY by its compounding, Piflufolastat, F-18 or PyL.

Along with our current Phase II trial for our 1095 product candidate, PyL is also included in several ongoing clinical trials for other prostate cancer therapeutics to assess PSMA expression with leading companies such as Bayer, Regeneron and Point Biopharma. Before I turn the call over to Paul to provide details on the PYLARIFY launch to date, I would like to share with you an image from our CONDOR trial. This image shows a 71 year old patient with a gleason score of four plus 3, a history of radical prostatectomy and external beam radiation therapy and equivocal results on an Axumin PET/CT scan, which is the image shown on the right side of this slide. This same patient was in image with PYLARIFY. The PYLARIFY image identifies less common iliac lesions and multiple retroperitoneal para/peri aortic lymph node lesions, which were later confirmed to be prostate cancer by biopsy. Similar to the results found here, PYLARIFY similarly demonstrated higher clarity results versus other forms of conventional imaging in our Phase III CONDOR study as well as in other studies. We are extremely excited about the potential of polarity. Now I'll turn the call over to Paul.

Paul Blanchfield -- Chief Commercial Officer

Thank you, Mary Anne, and good morning, everyone. It's a pleasure to be here to share our launch progress to date and our plans to maximize the potential of PYLARIFY to benefit the U.S. prostate cancer community, our customers and shareholders. In the two months since the FDA's approval of PYLARIFY, we have seen strong patient, customer and healthcare provider interest, and the approval was covered by multiple national and local media outlets. While today, I will not present product-specific sales data or current projections for PYLARIFY, I will share that post-approval, PYLARIFY has been used to image patients at freestanding imaging centers, hospitals and government facilities, with most of these sites already imaging multiple patients.

We are tracking these usage metrics closely and are pleased with the breadth of interest and recurrence of ordering that we are experiencing. Our manufacturing network now encompasses 12 PMS that have been activated to date, including the three largest metropolitan areas in the U.S.: New York, Los Angeles and San Diego and Chicago as well as select locations in the Southeast, the Midwest, the Southwest and the Northwest. We expect PYLARIFY availability to continue to expand across the U.S. over the remainder of the year, with broad nationwide availability by year-end. While we are discussing the scope of our PMF network, it's important to add that we have diversified our national manufacturing network across multiple partners and are confident that our network will be able to manufacture PYLARIFY at scale.

F-18 is a well-understood cyclotron manufactured isotope and PET manufacturing and PET imaging facilities have significant experience working with F-18. Indeed, F-18 is the radio isotope used in almost two million doses of FDG on an annual basis, and we have contracted with our PMF partners to ensure adequate supply to meet the polarity demand. As our PMF network expands, we are also investing in our commercial infrastructure, including hiring and training a dedicated field sales team supported by PYLARIFY specific contracting specialists and other home office resources as well as a market access team. We believe our commercial footprint, combined with the resources of our manufacturing partners will help imaging centers and prescribing physicians better access and realize the benefits of PYLARIFY, which include the advantages of PET imaging, the F-18 radio isotope, PSMA targeting and eventually incorporation of our proprietary artificial intelligence into reading scans, all of which should make PYLARIFY a best-in-class imaging agent for men with prostate cancer.

Lastly, a word about patient access. Our market access team has been laying the groundwork for reimbursement coverage with both governmental and commercial payers. We remain on track with our internal time lines for obtaining appropriate coding, pass-through status and progress with commercial payers related to ensure appropriate coverage and payment. This coordination with our PMF partners, commercial teams and commercial and government payers is critical to ensure we make PYLARIFY broadly available to the U.S. prostate cancer community and ensure that patients and facilities can be adequately reimbursed and covered for the use of this important agent. We believe PYLARIFY will make a significant contribution to the identification and treatment of prostate cancer, potentially impacting millions of men over the life cycle of the product. I'll now turn the call back to Mary Anne.

Mary Anne Heino -- President and Chief Executive Officer

Thank you, Paul. Now I'll review other commercial products and product candidates in our portfolio, starting with DEFINITY. Bob will speak to the actual revenue results as compared to the prior quarter and prior year, but I'm pleased to report that during the second quarter, DEFINITY demand exceeded pre-COVID-19 levels, while still very much dependent on geography and customers, over 50% of our DEFINITY sales team's promotional efforts are now in person, up from approximately 10% at the start of the year. Our sales representatives have look forward to reengaging in person with their customers. These positive trends, combined with our market-leading and stable share position have resulted in DEFINITY returning to strong revenue growth.

As we approach the 20th anniversary of DEFINITY's FDA approval at the end of this month, we believe the market opportunity for this agent remains significant, and we anticipate DEFINITY sales will continue to deliver sustainable growth. Moving to AZEDRA, we are pleased to see sales growing and with increased accessibility to customers, we've begun introducing changes to our customer approach, which we believe will optimize AZEDRA's availability as the only approved treatment for pheochromocytoma and paraganglioma. Several new centers of excellence have chosen to make AZEDRA available to their patients, and we have launched a new peer-to-peer education campaign to increase awareness of AZEDRA and its value to patients.

I'm pleased to report that the percentage of AZEDRA patients now completing the second dose of therapy is up significantly from last year. This is important because in the long-term follow-up of the pivotal trial for AZEDRA, the overall survival for patients who received two doses was more than twice as long as patients who received only a single dose. In June, we hired Kate Holland as Vice President, Radiopharmaceutical Therapy, Oncology. In this new role, Kate will lead both the sales and marketing teams for AZEDRA. Kate has held broad leadership roles across commercial functions in rare diseases, most recently with Harmony Biosciences and CSL Behring. We're excited to have Kate onboard, and we're confident that her leadership will contribute positively to our growth plans for AZEDRA. Moving on to our pipeline.

I'll discuss 1095, our iodine-131 PSMA-targeted therapeutic product candidate for the treatment of metastatic castrate-resistant prostate cancer, or mCRPC. In ARROW, our multicenter Phase II trial designed as a proof-of-concept study for 1095 in mCRPC, we are studying the combination of 1095 with enzalutamide in patients who have PSMA avid disease, or chemotherapy naive and to have progressed on abiraterone. PSMA avidity is determined by a PyL scan in this study. The primary endpoint is PSA response rate. Secondary endpoints include radiographic response, progression-free survival and overall survival. We plan to enroll approximately 120 patients in the study. We now have 25 clinical sites actively recruiting across the U.S. and Canada, and patient enrollment is progressing as planned. We will use our data from this proof-of-concept study to determine the next steps in our clinical development plan for 1095. I'll now turn the call over to Bob for a financial update.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Thank you, Mary Anne, and good morning, everyone. I will provide highlights for the second quarter financials, focusing on adjusted results unless otherwise noted. Turning to the quarter, revenue for the second quarter was $101.1 million, an increase of 53.1% over the prior year quarter, a comparison that includes the full impact on run rate revenues from the prior year of the COVID-19 pandemic and are now divested Puerto Rico operation as well as the partial contribution from the Progenics portfolio, namely RELISTOR. Beginning with precision diagnostics, revenue of $90.4 million was 43.6% higher from the prior year quarter. Sales of DEFINITY, net of rebates and allowances, were $59.8 million, 61.2% higher as compared to the prior year quarter, driven by sequentially higher volumes.

TechneLite net revenue was $23.8 million, up 27.3% from the prior year quarter on solid volumes supported by opportunistic generator sales. Within other precision diagnostics, Xenon's performance has continued at similar levels to the previous sequential four quarters. Radiopharmaceutical oncology contributed $2.8 million of sales, up 28.8% from the prior year quarter due mainly to promising and solid performance from AZEDRA, offset in part by the loss of revenue tied to the strategic divestiture of the Puerto Rico operation. As a reminder, in addition to AZEDRA, PYLARIFY and QUADRAMET reside within this revenue category. Lastly, strategic partnerships and other revenue was $7.9 million, driven primarily by the RELISTOR royalty.

Also, during the quarter, we completed the sale of cREPO, a cardiac artificial intelligence software solution to a strategic partner for the Japanese market. Gross profit margin for the second quarter was 52.6%, an increase from 41.7% posted in the second quarter of 2020 on a similar basis. The increase is due mainly to the impact of COVID-19 in the prior year comparison. In the current year, favorable product mix led by DEFINITY volumes was partially offset by an extended manufacturing footprint acquired with Progenics on a year-over-year comparable basis as well as increased Moly distribution and logistics costs due to the COVID-19 pandemic. Operating expenses were 12.7% unfavorable to the prior year at 42.4% of net revenue, driven primarily by the continued annualization of expenses from Progenics, offset in part by synergy achievement.

Commercial efforts for DEFINITY and the investments in PYLARIFY commercialization as well as the continued progress on our 1095 ARROW clinical study accounted for the increased level of spend from the first quarter this year, but in line with expectations. Additionally, it's also worth noting that the company had enacted a number of cost savings initiatives in the prior year quarter to counter the impacts of COVID-19 on our financials, which drives some unfavorability in comparison with spend normalization in the current year. Operating profit for the quarter was $10.4 million or an increase of 30.8% over the same period prior year. Total adjustments in the quarter totaled $37.2 million of expense before taxes. Of this amount, $4.6 million and $6.1 million of expense is associated with noncash stock incentive plans as well as acquired intangible amortization.

Also in the quarter, we recorded a $25.6 million net expense adjustment to contingent assets and liabilities, including the PYLARIFY CVR contingent liability, which was the main driver. The CVR contingent liability fair value is determined quarterly using a Monte Carlo simulation. Assumptions in the model include the company's then current forecast, estimate of future volatility and utilization of an appropriate discount rate. The remainder is related to acquisition, integration and other nonrecurring expenses. Our effective tax rate was 9.9% in the quarter and 27% year-to-date and reflects the impact of the treatment for the capital gain associated with the divestiture of our Puerto Rico operation and contingent consideration adjustments. Additionally, in the quarter, we released a portion of our uncertain tax position or UTP provisions based on newly acquired information, which had a modest impact of lowering our effective tax rate.

The resulting reported net income for the second quarter was a loss of $26.7 million and a profit of $7.8 million on an adjusted basis, an increase of 71.6%. GAAP fully diluted earnings per share were a loss of $0.39 and a profit of $0.11 on an adjusted basis, an increase from the prior year of 8.1%. Notably, the earnings per share for the quarter were based on weighted average fully diluted shares outstanding that were approximately 58.7% higher on a year-over-year basis due to the Progenics acquisition, which closed last June. Now turning to cash flow. Second quarter operating cash flow totaled $25.9 million as compared to a use of $2.2 million in Q2 2020. Capital expenditures totaled $2.7 million, up slightly from the prior year quarter. Free cash flow, which we define as operating cash flow less capital expenditures was $23.2 million, an increase of $27.6 million over the prior year period.

Cash and cash equivalents, net of restricted cash now stands at $91.5 million. We continue to have access to our $200 million undrawn bank revolver and are comfortable with our strong liquidity position. Now turning to guidance for Q3 and the full year. We forecast revenue to be in a range of $95 million to $100 million for the third quarter of 2021, an increase of approximately 7% and 13% over the third quarter of 2020. The range takes PYLARIFY into consideration as well as ongoing strength of DEFINITY and the impact of the recurrent summer seasonality on sales. Additionally, we are updating our full year view due to trends in our underlying core business. Therefore, we now forecast revenue to be in the range of $395 million to $402 million from the prior range of $390 million to $400 million.

Lastly, during the quarter, it is important to note, we made a strategic decision to exit one of our TechneLite contracts, which carries a $5 million net revenue impact on the second half of this year. Our revenue forecast for Q3 and full year have taken this impact into consideration. Regarding adjusted earnings per share, we remain committed to investing in revenue growth initiatives. Taken together, adjusted EPS should be in the range of $0.05 to $0.07 for the third quarter. We are raising our full year adjusted EPS to account for relative year-to-date outperformance, offset in part by incremental pipeline assets -- incremental pipeline investments. As such, we now expect adjusted EPS to be in a range of $0.38 to $0.42 per share versus the prior range of $0.36 to $0.41. This forecast does not include a tax credit we anticipate applying for as part of COVID-19 related government programs in the near-term. You can find more information on this topic in our 10-Q filed this morning. With that, let me turn the call over to Mary Anne.

Mary Anne Heino -- President and Chief Executive Officer

Thank you, Bob. As you can see, the second quarter was a successful and productive one for Lantheus. With the approval and launch of PYLARIFY, strong DEFINITY performance and continued financial strength informing full year guidance, we are confident about our growth momentum and our ability to deliver shareholder value. Before I open the call to questions, I would like to recognize the progress we've made, not only this quarter, but also year-to-date, all against the uncertain backdrop of continued evolving global pandemic events. As always, the performance of Lantheus is made postal only by our committed employees who continue to work tirelessly to guarantee we best serve our patients, healthcare providers, customers and shareholders who place their trust in us. I recognize, thank and appreciate them for their efforts. With that, Bob, Paul and I are now ready to take your questions. Operator, please go ahead.

Questions and Answers:

Operator

[Operator Instructions] And our first question comes from the line of Richard Newitter from SVB Leerink.

Richard Newitter -- SVB Leerink -- Analyst

Good morning. Thanks for taking the question. Wanted to maybe start off on PYLARIFY contribution that's anticipated or baked into your outlook for the back half. If you could just give us a sense as to what you're assuming, if anything, for 3Q contribution? The consensus kind of had a 2021, about $5 million to $6 million placeholder in there. In light of the $5 million impact that you mentioned exiting the TechneLite contract, I'm just curious about the moving parts there. Did your -- is that the right placeholder for PYLARIFY? Or is PYLARIFY maybe a little higher now that you have approval and what you see there that counters that $5 million that's coming out from TechneLite?

Mary Anne Heino -- President and Chief Executive Officer

Good morning Rich, I'm going to let Bob take that one. We're -- as you know, we're not giving specific guidance on -- product-specific guidance on PYLARIFY, but I'll let Bob give you some general range there.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

All right. Great. Good morning Rich. So as you think about the guidance for Q4. I think you -- industry generally understand that the launch is just getting underway. And as such, I do think that things have been modeled appropriately, the makeup, if you will, of the TechneLite contract really is coming off the strength of the underlying business. And so what I'm really pointing to there is DEFINITY is doing extremely well. We're very pleased with the progress its making. And as you can see in this morning's results from Q2, returning to pre-pandemic levels. Of course, there's a little bit of seasonality. Q3 is generally going to be our lower sort of sales revenue quarter. But fourth quarter is generally our highest revenue quarter for the year. So in the forecast is our -- is already considered polarity. I mean we did have it baked some of it earlier because we had high confidence in approval as it went forward. But I do think that what has been sort of modeled feels appropriate as we get this underway. And as we have continuously said, we think 2022 is the real sort of takeoff for polarity.

Richard Newitter -- SVB Leerink -- Analyst

Thanks. That's helpful. What was the reason for the contract exit of TechneLite, how do we think about that going forward? Is that just $5 million that kind of goes away forever in a new base? And then I'm just curious, if not for that, would your guidance likely have been $5 million higher or else equal?

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Let me just address. So the $5 million is across the entirety of the second half, Rich, so it would be sort of think of it evenly spread between Q3 and Q4. But Mary Anne, let me-

Mary Anne Heino -- President and Chief Executive Officer

Yes. I'll address the larger issue. Your question about does it go away forever. These contracts are negotiated at this point almost on an annual basis, and that's more about the dynamics in the market that we see occurring really in the radio pharmacy market. And my stance on this, and we chose voluntarily not to enter into what we saw as a noxious contract this particular contract. We did -- we had a similar situation back in 2015 where we took the same decision.

And I will say, honestly, at the time, it was a much bigger decision for the company because, at that time, that contract represented a much more significant piece of business for the company on a much smaller revenue base, and we still took the stand to say that we would not enter into an noxious contract because we don't see it as being healthy for the market. And that's the same stand we're taking today. But I would not take it as a permanent decision. Back in that time frame, within a few quarters, we were back in contracted -- full contracted status with that customer and that's I would say, the nature of this market more than anything else.

Richard Newitter -- SVB Leerink -- Analyst

Okay. But if that -- if you don't negotiate something on terms, you find appropriate or reasonable, that will be an annualized $10 million that would theoretically kind of have to come out from whatever one was thinking about '22 prior. Is that right?

Mary Anne Heino -- President and Chief Executive Officer

So I'm not going to agree with that statement, Rich, because that means that we would not change the amount of business that we have with the other players in the market. And it means the other players in the market might not pick up more share of the market, and that is a fluid event that we see.

Richard Newitter -- SVB Leerink -- Analyst

Okay very helpful. [Inaudible]

Operator

And our next question comes from the line of Anthony Petrone from Jefferies.

Anthony Petrone -- Jefferies -- Analyst

Hi, Thank you. Couple of questions, Mary Anne. First, congratulations on, again, a strong year so far, clarified clearance. My questions would be on PET manufacturing facility clearances, I know you had several secured heading into launch, and there was more coming on in the next six months. So just kind of looking to get an update there, how many will be in place starting in 2022? And then maybe a bit of an update on the CMS pass-through code, also an initiative that was evolving into 2022? And then lastly, I'll just throw it in. Just on the commercial side, any updates there on reimbursement for PYLARIFY? Thank you.

Mary Anne Heino -- President and Chief Executive Officer

Terrific. Good morning Anthony, I'm actually going to point and let Paul speak to all that because he's much closer to it. When you hear me off in some of those facts, I usually get them right from Paul. So I'll let him address them directly.

Paul Blanchfield -- Chief Commercial Officer

Thanks for the question. So I take it in two parts. The first part was related to PMF activation and our rollout plans and the second related to our CMS pass-through. So I'll take the first part. As we mentioned, we do have 12 PMF sites activated across the country, including the three largest metropolitan areas of New York, Southern California, Los Angeles as well as Chicago. We do have plans to roll that out and to expand our commercial footprint across the major football cities in the United States to get to more than, as you'll see on pylarify.com, more than 30 sites by the end of the year, which would get us to the vast majority of coverage for the U.S. marketplace by year-end.

Which aligns, as I segue to the second piece around our pass through status. As we have conveyed, we do plan to submit our pass-through application by September one of this year, which would coincide with activation of pass-through for the Medicare hospital outpatient setting, which is obviously very important for this patient community to go into effect January 1, 2022, which would align with our PMF activation coverage to cover the majority of the market. And so we feel those two are very well synced to support continued growth of PYLARIFY, not only through this year, but as Bob mentioned, in 2022.

Anthony Petrone -- Jefferies -- Analyst

Thank you very much.

Paul Blanchfield -- Chief Commercial Officer

Thank you.

Mary Anne Heino -- President and Chief Executive Officer

Anything else, Anthony?

Anthony Petrone -- Jefferies -- Analyst

Just my follow-up would be on DEFINITY. Just in terms of looking at, obviously, ESGs, there was procedure backlog due to COVID. It looks like, certainly, some of that came back in the quarter. So maybe just a little bit of update on echocardiogram landscape, is there a way to sort of quantify what the backlog still is at the moment, if there is still one? And how long of a tailwind is that perhaps into later this year or early into '22? Thanks

Mary Anne Heino -- President and Chief Executive Officer

So that's a little bit of a tricky question now, Anthony, because as Bob mentioned, this period of the year is usually one where we tend to see what we call either seasonality or vacationality because you tend to have a little bit of a lull in procedures being done because of both patients being on vacation and then staffing on vacation. So now we're trying to kind of say, is that not going to happen? Are people less likely because of trying to catch up with, as you say, what is the backlog.

So we really won't know the answer to that until we see the data in retrospect because we -- that's something we only see as -- in retrospect, not in -- we can't see it in real time. But as I said, what we have seen to date is we've seen strong rebound, and we are now at a point where we see DEFINITY performance exceeding for the data we have, DEFINITY performance exceeding pre-pandemic levels. We assume that, that is because the underlying market, which is echo procedures in general, that they're in fact driving that performance. But again, until we see the data in retrospect, we can't confirm that.

Operator

And our next question comes from the line of Larry Solow from CJS Securities.

Larry Solow -- CJS Securities -- Analyst

Thanks guys. Just a couple of sort of high-level questions. I realize you can't really quantify sales and whatnot. But just on the initial PYLARIFY sales, just curious if you have any anecdotal thoughts on doctor awareness, patient awareness as the drug came out or as the tracer came out and initial sales, can you just give us any feel? Are they going toward docs or using zoom in are these new docs? Any color on that would be great.

Mary Anne Heino -- President and Chief Executive Officer

Good morning. As we mentioned, we'll not be offering specific data on PYLARIFY sales. I think -- and I'll let Paul speak to this. We were very pleasantly -- I wouldn't say surprised, but we were pleased with the amount of coverage that PYLARIFY received at launch, and Paul can elaborate a little bit on that.

Paul Blanchfield -- Chief Commercial Officer

Yes, absolutely, Mary Anne. So I think we're incredibly pleased with PYLARIFY, the first and only commercially available FDA-approved PSMA PET imaging agent was picked up by many media outlets across the country. We have seen, as we've mentioned, PYLARIFY be ordered at multiple types of centers, whether that's freestanding imaging centers, hospitals, government facilities, the vast majority of these are already ordering multiple scans. And so we have seen strong uptake. I would note that with the approval, we received activation of two specific PMFs, and we've been rolling that out more where we are now up to 12 as of the middle of July. It is important to note that, as I mentioned, in building out our commercial infrastructure, we are driving awareness.

There was significant media attention. Physicians and the healthcare community are certainly aware of PYLARIFY and what this product could mean to the U.S. prostate cancer community. But we do have our own dedicated marketing and sales teams that are out there, making sure that physicians, healthcare professionals and imaging centers are aware of the benefits of PYLARIFY as, Mary Anne, noted the four major benefits. We're out there actively ensuring that we are not only making awareness, but building the market to ensure that we have a successful launch this year and in years to come.

Mary Anne Heino -- President and Chief Executive Officer

So I think, Larry, we had to be somewhat humble about this. We'd like to believe that it's on the tip now of everybody's tongue, but this is a classic launch where you have to build awareness, we're building our PMF network, but we're also, as Paul said, building what is the slow and steady awareness of what the benefits of the product are, how do you use the product, where do you use the product, we're confident that, that will all come to fruition, but we're taking it very seriously as a very classic launch of what will be a long-held product in the market, and that's how we're treating it.

Larry Solow -- CJS Securities -- Analyst

No, absolutely. Can you just help -- just in terms of building out your SG&A infrastructure, particularly on the SG -- on the sales and marketing side. Obviously, you're at a run rate now of, I think, like $65 million, $70 million, I think up from like $40 million last couple of years, pre-Progenics, pre-PyL. Do we see significantly more increases in this number? I mean, does it go to 100 over the next couple of years? Or is it just more or less -- continue to grow, but maybe not that fast? Any qualification here would be great.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Larry thanks. No, I keep the financials in a very tight fist, as Paul would probably attribute to me. I think what you're seeing is the ramp that you saw from Q1 to Q2, is how you should sort of think -- you remember, I had said, thinking total opex of about $40 million to $45 million. As we get to the back half of the year, you saw we were at $42.8 million this year, I mean for this quarter. Maybe it's a little bit more, but that has a lot to do with activities that are also in R&D. But you should expect that we're going to normalize and sort of flatten out very close to where we are at the moment.

I do not anticipate a continued ramp. I would expect profitability to sort of really kind of manifest itself as you think in terms of Q4, Q1, Q2 kind of thing because we're hitting that peak spend level to whereby we can now drive sustainable top line growth. So we've been making the preinvestment to help support the commercial teams, to support R&D, hold back office sort of in check, which is where you see the synergies that we took that we were then able to sort of reinvest at least in the near-term to be able to drive that sustainable growth longer term. So I do think you're seeing I would expect gross margin to continue to improve, but I would also expect to see expenses level out.

Larry Solow -- CJS Securities -- Analyst

Okay. And then just I noticed in the Q, the fair value of the CVR related to PyL PYLARIFY actually went up. Is that strictly primarily, at least just a function of you got approval, it's on the market, it's closer to potentially getting some of those -- hitting some of those thresholds. Is that based on that? Or is there anything else you can discuss on that?

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Yes. I mean, so the way you determine the continued liability in this case, fair value, you do take what is a then current internal forecast. And from that perspective, then you run it through Monte Carlo simulation, which has embedded volatility assumptions as well as an approach with discount rate. And now it's really kind of in that discount rate where you attribute to did you derisk things like was it approved or not approved? Or is there still execution risk and so forth and so on, which I think is also potentially embedded in the volatility aspect of it. So I think -- so it is a function -- it's a multifactorial type of output -- input and then output. And so I think the key for people here is, one, it gets determined quarterly. So as any of these inputs change, so can then the value of this contingent liability. So what people should not infer is this is some sort of long-range forecast or guidance that we're providing. But it is an accounting mechanism that takes all of these different inputs into consideration as we look forward.

Larry Solow -- CJS Securities -- Analyst

Okay. Great. Fair enough. Just last question on DEFINITY. Obviously, you mentioned market opportunity remains significant. Any reason to believe that as we -- obviously, still some noise and whatnot from COVID, but hopefully, that begins to wane or continues to wane. Any reason as we settle down, maybe starting from 2022 that this can't -- DEFINITY won't be returned to sort of its double-digit growth, maybe not at that 20% it had -- what we see over the last few years, but double-digits, is that a fair assumption?

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

So as I said, we're already exceeding pre-pandemic levels. So we're seeing performance that already matches what we were seeing pre-pandemic. Now I want to make sure we're being realistic here because you put the range there yourself. Pre-pandemic, we were already not at 20%, we were double-digit, as you said, but I think what we were hoping, ranging those-

Larry Solow -- CJS Securities -- Analyst

Mid-teens, yes.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Yes, teens, mid-teens there. And this is something that we do want because of the relevance of DEFINITY to our forecast into our revenue, we do report as out of singularly. So you'll see the DEFINITY performance ejected this quarter.

Paul Blanchfield -- Chief Commercial Officer

Yes. Larry, when I look at the 2-year stack, even just for Q2, that number is, I think, what, about 17% or so. So it sort of put that performance. This is where we kind of get the confidence in saying, are we back at pre-pandemic levels? Well, it sort of looks like that teens growth that we would have expected, which even to what Mary Anne was talking about in terms of backlog, and we won't know that for a while, but this would imply more of a sort of a normalized market environment.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

And I'll say, and Paul weigh in here as well. It's a significant asset for us. We have a dedicated business linked to it. Paul and team did a great job earlier this year as we do every year, looking at what are the resources needed to continue to support this asset.

Paul Blanchfield -- Chief Commercial Officer

I think we remain very optimistic about DEFINITY's future. We're coming up on the 20th anniversary of DEFINITY's FDA approval at the end of this month, but we believe the market opportunity for this agent remains significant. There is still a significant number of suboptimal echos out in the marketplace that could benefit from the use of an ultrasound enhancing agent, and we maintain our 80% market share as the contrast agent of choice and believe that DEFINITY sales will continue to grow into the future.

Mary Anne Heino -- President and Chief Executive Officer

Our tag line inside is for DEFINITY '20 is the new 5.

Larry Solow -- CJS Securities -- Analyst

I appreciate the call. Thanks on that.

Paul Blanchfield -- Chief Commercial Officer

Your welcome.

Operator

And our next question comes from the line of Erin Wright from Credit Suisse.

Erin Wright -- Credit Suisse -- Analyst

Hi, thanks. How are you thinking about the potential tailwind from Novartis' potential prostate cancer therapeutic, could that be meaningful for you? And then a second kind of question here, just given some of the protocols associated with Biogen Alzheimer's approval could increase PET scans tied to that approval if that at all represent an opportunity for you as well?

Mary Anne Heino -- President and Chief Executive Officer

So Erin, good morning. this is Mary Anne. I think you're bringing up a great point about the larger market and the role of isotopes in the market and PET scanning in the market. Certainly, the Alzheimer's product speaks to the role of PET scanning and companion diagnostics in the market, which we're thrilled about because that is for the future of Lantheus, that's an area that we -- not particularly Alzheimer's, but that's a larger area where we intend to be very strategically involved, and that is the use of isotopes and isotope-related products in overall treatment diagnostically and therapeutically. From -- for the -- specifically for the Novartis product, while that comes to market, and we were also thrilled to see the readout it had and the efficacy associated there because we have our own products in our pipeline in a similar fashion.

We think there, again, that demonstrates the positive role that companion diagnostics will have. You heard me mention earlier that PyL has been chosen as the companion diagnostic with companies such as Regeneron, Bayer and Point Biopharma. That really points to the -- what we are doing with our pharma services group, which is really becoming the partner of choice for a lot of the work that's going on in clinical development, where these types of biomarkers are being used not only to make clinical development more efficient, but really to ensure that patients are getting drugs so that have a higher likelihood of being therapeutically valuable to them. And that decision is being made earlier and earlier in clinical development, and we're thrilled to be part of that.

Erin Wright -- Credit Suisse -- Analyst

Okay. Great. And then on DEFINITY, could you give us an update on the competitive landscape, what you're seeing now and where market share stands? Is it still roughly in that 80% sort of range?

Mary Anne Heino -- President and Chief Executive Officer

I'm going to let Paul speak to that because he's much closer to it.

Paul Blanchfield -- Chief Commercial Officer

Thanks, Mary Anne. Yes. So on the competitive dynamics, we still see ourselves as the market leader with roughly 80% share of the U.S. marketplace. We see continued growth. We have maintained a leadership position and remain the contrast agent of choice across the marketplace. And so we remain very pleased after 20 years to still be able to be the preferred partner across echo labs around the country and continue to grow as we support our customers and ensure they understand the benefits that DEFINITY brings to their practices.

Erin Wright -- Credit Suisse -- Analyst

Okay great. Thank you.

Operator

And we do have a follow-up question from Richard Newitter from SVB Leerink.

Richard Newitter -- SVB Leerink -- Analyst

Hi. Thanks for taking the follow-up. Just because I'm getting asked the question, I'm just going back to what I had asked earlier, I want to make sure I'm clear. The $5 million impact of TechneLite that gets spread out evenly roughly between 3Q and 4Q. I guess just if not for that, given that you're still raising your full year guidance, would your guidance have gone up by even more? In other words, if not for that? In other words, is DEFINITY's momentum underlying getting baked into your back half guide as continuing, and therefore, that marginally offsets some of the headwind that, that TechneLite creates?

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Rich, more or less, yes. I mean, it really is sort of ongoing trends that we see in DEFINITY, taking into account the seasonality of things. But it is what is making up the difference, more or less, yes. And there are a lot of other pieces and parts that are moving within timing of Neurolite and Cardiolite and so forth and so on. I mean, so it is a function of DEFINITY, the underlying core business. But of course, we have -- and take PYLARIFY baked into this as well. But what is -- you say, when we have had higher guidance, it would have been marginally different potentially.

But again, there's also an external environment against which we are guiding into that we still want to -- even in Mark's opening remarks that we have a delta variant that's out there causing a lot of news, but not necessarily headwind. So we are cautious in the way we think about things. But at the same time, we're very confident in our underlying business. The core business is doing extremely well. It's embedded in the results. You can see it. And that's what led us to have the ability to sort of move our guidance range for the full year to account for our relative performance year-to-date and then our where we see that business going on -- through the balance of this year.

Richard Newitter -- SVB Leerink -- Analyst

Okay. That's helpful. And just two other product questions. AZEDRA and RELISTOR. Just first on AZEDRA, you said you had a lot of promise in 2Q. It sounds like you're really building the stage for a much steeper or setting the stage for a much steeper kind of sequential ramp moving through the year into '22. But is that the right way to think about it? And how much of a contributor should we be thinking about for AZEDRA in 2021? Or is this really going to be a 2022 product? And same thing with RELISTOR, what's the run rate? The performance you saw in 2Q kind of sustainable by a quarter going forward?

Mary Anne Heino -- President and Chief Executive Officer

I'll speak to AZEDRA first, Rich, because I do want you to hear what I said promising is the right word here, but I think you need to understand the base. When you talk about steep ramps, you need -- what we're jumping off from. And I'll jump off from the comments I've made before. I've been really clear that we felt -- and it was true. We were blocked access to customers really throughout the pandemic with AZEDRA because we -- what we didn't have coming into the pandemic is we didn't have relationships really already built with those customers. That was from a -- just from a historic perspective, that was Lantheus didn't kind of own those relationships before the acquisition. And they were very, I would say, kind of young and only forming relationships that Progenics have had. So that was really a relationship that was fairly shut down by the pandemic.

And as you heard me say today, that is something that now more recently, we've seen accessibility to those customers really start to reopen. And so we've been able to begin executing on what we've said all along we would do with the acquisition, which was to really bring change to what the model is of how to interact for that particular asset with the community that of patients and caretakers and treaters that are necessary to really kind of bring the awareness there. And now we're starting to see some results, and we're really pleased with what we saw in the second quarter. And that's a beginning for us of what we see is what the optimal -- kind of the optimal promises for that product. But I need to be really clear, this is not a PYLARIFY from magnitude of what's possible. It is an orphan disease.

And so the magnitude of what is possible from a revenue perspective is not what we are talking about when we talk about PYLARIFY. But we are, as an executive team and as a company, we are always committed to optimizing the assets that have been entrusted to us, and we will do that with AZEDRA. So the promising is the right word, ramp is the right word, but I want you from a modeling perspective, especially, to think about what the base of that ramp is and how to ramp up. Kate Holland is a great talent add to our company. I will tell you, I've worked with her before. And that's why I know she's great talent to add to our company, and we are confident that with the -- also with the team now and with some of the resources we have that we will be able to do right for AZEDRA and right for the patients that is AZEDRA patients. I think part of the promising signs we see there is, as I said, more treatment centers have now decided to have AZEDRA offerings at their treatment centers, which is also great news for the patients who need it. I'm going to let Bob speak to RELISTOR.

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Yes. So I mean, one, just to level set to one size. I mean you can look at our radiopharmaceutical oncology, which is where AZEDRA sits from a total revenue contribution perspective, I mean, it is the main driver of that number, which I have noted. RELISTOR, we have continuously been able to tell people at a pretty steady stream, which has ranged between $4.5 million and $5 million. We're tending toward the higher end of that range in more recent quarters, and we're very pleased with the ongoing contribution that we're seeing from our partner. So -- and at this juncture, we don't control it, so we can't sort of speak to what the future trends might be. But what we're experiencing now is very solid and very pleased with it.

Richard Newitter -- SVB Leerink -- Analyst

Okay. Thank you.

Operator

[Operator Instructions] We show no further questions at this time. [Operator Closing Remarks]

Duration: 54 minutes

Call participants:

Mark Kinarney -- Senior Director, Investor Relations

Mary Anne Heino -- President and Chief Executive Officer

Paul Blanchfield -- Chief Commercial Officer

Robert J. Marshall Jr. -- Chief Financial Officer and Treasurer

Richard Newitter -- SVB Leerink -- Analyst

Anthony Petrone -- Jefferies -- Analyst

Larry Solow -- CJS Securities -- Analyst

Erin Wright -- Credit Suisse -- Analyst

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