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Emmett L, Subramaniam S, Crumbaker M, Nguyen A, Joshua AM, Weickhardt A, Lee ST, Ng S, Francis RJ, Goh JC, Pattison DA, Tan TH, Kirkwood ID, Gedye C, Rutherford NK, Sandhu S, Kumar AR, Pook D, Ramdave S, Nadebaum DP, Voskoboynik M, Redfern AD, Macdonald W, Krieger L, Schembri G, Chua W, Lin P, Horvath L, Bastick P, Butler P, Zhang AY, Yip S, Thomas H, Langford A, Hofman MS, McJannett M, Martin AJ, Stockler MR, Davis ID. [ 177Lu]Lu-PSMA-617 plus enzalutamide in patients with metastatic castration-resistant prostate cancer (ENZA-p): an open-label, multicentre, randomised, phase 2 trial. Lancet Oncol 2024; 25:563-571. [PMID: 38621400 DOI: 10.1016/s1470-2045(24)00135-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/23/2024] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Enzalutamide and lutetium-177 [177Lu]Lu-prostate-specific membrane antigen (PSMA)-617 both improve overall survival in patients with metastatic castration-resistant prostate cancer. Androgen and PSMA receptors have a close intracellular relationship, with data suggesting complementary benefit if targeted concurrently. In this study, we assessed the activity and safety of enzalutamide plus adaptive-dosed [177Lu]Lu-PSMA-617 versus enzalutamide alone as first-line treatment for metastatic castration-resistant prostate cancer. METHODS ENZA-p was an open-label, randomised, controlled phase 2 trial done at 15 hospitals in Australia. Participants were men aged 18 years or older with metastatic castration-resistant prostate cancer not previously treated with docetaxel or androgen receptor pathway inhibitors for metastatic castration-resistant prostate cancer, gallium-68 [68Ga]Ga-PSMA-PET-CT (PSMA-PET-CT) positive disease, Eastern Cooperative Oncology Group performance status of 0-2, and at least two risk factors for early progression on enzalutamide. Participants were randomly assigned (1:1) by a centralised, web-based system using minimisation with a random component to stratify for study site, disease burden, use of early docetaxel, and previous treatment with abiraterone acetate. Patients were either given oral enzalutamide 160 mg daily alone or with adaptive-dosed (two or four doses) intravenous 7·5 GBq [177Lu]Lu-PSMA-617 every 6-8 weeks dependent on an interim PSMA-PET-CT (week 12). The primary endpoint was prostate-specific antigen (PSA) progression-free survival, defined as the interval from the date of randomisation to the date of first evidence of PSA progression, commencement of non-protocol anticancer therapy, or death. The analysis was done in the intention-to-treat population, using stratified Cox proportional hazards regression. This trial is registered with ClinicalTrials.gov, NCT04419402, and participant follow-up is ongoing. FINDINGS 162 participants were randomly assigned between Aug 17, 2020, and July 26, 2022. 83 men were assigned to the enzalutamide plus [177Lu]Lu-PSMA-617 group, and 79 were assigned to the enzalutamide group. Median follow-up in this interim analysis was 20 months (IQR 18-21), with 32 (39%) of 83 patients in the enzalutamide plus [177Lu]Lu-PSMA-617 group and 16 (20%) of 79 patients in the enzalutamide group remaining on treatment at the data cutoff date. Median age was 71 years (IQR 64-76). Median PSA progression-free survival was 13·0 months (95% CI 11·0-17·0) in the enzalutamide plus [177Lu]Lu-PSMA-617 group and 7·8 months (95% CI 4·3-11·0) in the enzalutamide group (hazard ratio 0·43, 95% CI 0·29-0·63, p<0·0001). The most common adverse events (all grades) were fatigue (61 [75%] of 81 patients), nausea (38 [47%]), and dry mouth (32 [40%]) in the enzalutamide plus [177Lu]Lu-PSMA-617 group and fatigue (55 [70%] of 79), nausea (21 [27%]), and constipation (18 [23%]) in the enzalutamide group. Grade 3-5 adverse events occurred in 32 (40%) of 81 patients in the enzalutamide plus [177Lu]Lu-PSMA-617 group and 32 (41%) of 79 patients in the enzalutamide group. Grade 3 events that occurred only in the enzalutamide plus [177Lu]Lu-PSMA-617 group included anaemia (three [4%] of 81 participants) and decreased platelet count (one [1%] participant). No grade 4 or 5 events were attributed to treatment on central review in either group. INTERPRETATION The addition of [177Lu]Lu-PSMA-617 to enzalutamide improved PSA progression-free survival providing evidence of enhanced anticancer activity in patients with metastatic castration-resistant prostate cancer with risk factors for early progression on enzalutamide and warrants further evaluation of the combination more broadly in metastatic prostate cancer. FUNDING Prostate Cancer Research Alliance (Movember and Australian Federal Government), St Vincent's Clinic Foundation, GenesisCare, Roy Morgan Research, and Endocyte (a Novartis company).
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia; Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Shalini Subramaniam
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Bankstown-Lidcombe Hospital, Sydney, NSW, Australia
| | - Megan Crumbaker
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia; Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia; Garvan Institute of Medical Research, Sydney, NSW, Australia; Macquarie University Hospital, Sydney, NSW, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia; St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Anthony M Joshua
- Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia; Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Andrew Weickhardt
- Olivia Newton-John Cancer and Wellness Centre, Austin Health, Melbourne, VIC, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia
| | - Sze-Ting Lee
- Department of Molecular Imaging and Therapy, Austin Health, Melbourne, VIC, Australia; School of Cancer Medicine, La Trobe University, Melbourne, VIC, Australia; Olivia Newton-John Cancer Research Institute, Melbourne, VIC, Australia; Department of Medicine and Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
| | - Siobhan Ng
- Department of Oncology, Sir Charles Gairdner Hospital, Perth, WA, Australia; Department of Oncology, University of Western Australia, Perth, WA, Australia
| | - Roslyn J Francis
- Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia; Medical School, University of Western Australia, Perth, WA, Australia
| | - Jeffrey C Goh
- Department of Medical Oncology, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; Queensland University of Technology, Brisbane, QLD, Australia
| | - David A Pattison
- Department of Nuclear Medicine and Specialised PET Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Thean Hsiang Tan
- Department of Medical Oncology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Ian D Kirkwood
- Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, SA, Australia; Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Craig Gedye
- Department of Medical Oncology, Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Natalie K Rutherford
- Department of Nuclear Medicine, Hunter New England Health, Newcastle, NSW, Australia
| | - Shahneen Sandhu
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia; Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Aravind Ravi Kumar
- Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - David Pook
- Department of Oncology, Monash Health, Melbourne, VIC, Australia
| | - Shakher Ramdave
- Monash Health Imaging, Monash Health, Melbourne, VIC, Australia
| | - David P Nadebaum
- Department of Oncology, Alfred Health, Melbourne, VIC, Australia
| | - Mark Voskoboynik
- Department of Oncology, Alfred Health, Melbourne, VIC, Australia; Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Andrew D Redfern
- Medical School, University of Western Australia, Perth, WA, Australia; Department of Medical Oncology, Fiona Stanley Hospital, Perth, WA, Australia
| | - William Macdonald
- Medical School, University of Western Australia, Perth, WA, Australia; Department of Nuclear Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | | | - Geoff Schembri
- Nuclear Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Wei Chua
- Department of Medical Oncology, Liverpool Hospital, Sydney, NSW, Australia; Western Sydney University, Sydney, NSW, Australia
| | - Peter Lin
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Department of Nuclear Medicine and PET, Liverpool Hospital, Sydney, NSW, Australia
| | - Lisa Horvath
- Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Patricia Bastick
- Department of Medical Oncology, St George Hospital, Sydney, NSW, Australia
| | - Patrick Butler
- Department of Nuclear Medicine, St George Hospital, Sydney, NSW, Australia
| | - Alison Yan Zhang
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Macquarie University Hospital, Sydney, NSW, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Sonia Yip
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Hayley Thomas
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Ailsa Langford
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia; Prostate Cancer Theranostics and Imaging Centre of Excellence (ProsTIC), Molecular Imaging and Therapeutic Nuclear Medicine, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Margaret McJannett
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Sydney, NSW, Australia
| | - Andrew James Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia; Department of Medical Oncology, Chris O'Brien Lifehouse, Sydney, NSW, Australia
| | - Ian D Davis
- Monash University Eastern Health Clinical School, Melbourne, VIC, Australia; Eastern Health, Melbourne, VIC, Australia
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Swiha M, Papa N, Sabahi Z, Ayati N, John N, Pathmanandavel S, Crumbaker M, Li S, Agrawal S, Ayers M, Hickey A, Sharma S, Nguyen A, Emmett L. Development of a Visually Calculated SUV mean (HIT Score) on Screening PSMA PET/CT to Predict Treatment Response to 177Lu-PSMA Therapy: Comparison with Quantitative SUV mean and Patient Outcomes. J Nucl Med 2024:jnumed.123.267014. [PMID: 38637137 DOI: 10.2967/jnumed.123.267014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
177Lu-PSMA therapy is an effective treatment in patients with metastatic castration-resistant prostate cancer. SUVmean is a valuable screening biomarker to assess the suitability for 177Lu-PSMA therapy but requires quantitative software. This study aims to develop a simple, clinically applicable prostate-specific membrane antigen PET/CT score that encompasses the elements of SUVmean without requiring additional quantification. Methods: Datasets from ethics-approved trials of patients with metastatic castration-resistant prostate cancer after androgen receptor signaling inhibition and taxane chemotherapy (or unfit for taxane), who were treated with 177Lu-PSMA-617 and 177Lu-PSMA I&T with a pretreatment screening with 68Ga-PSMA-11 PET/CT, and clinical outcome data, including a prostate-specific antigen (PSA) 50% response rate (PSA50), PSA progression-free survival (PSA-PFS), and overall survival (OS), were included. The screening 68Ga-PSMA-11 PET/CT of all participants was analyzed both semiquantitatively and visually. Semiquantitative analysis was used to derive the SUVmean Visual analysis of the 68Ga-PSMA-11 PET/CT images involved a binary visual heterogeneity assessment (homogeneous or heterogeneous), allocating a tumor SUVmax range (<15, 15-29, 30-49, 50-79, or ≥80). A 4-category score incorporating both heterogeneity and intensity of tumors (HIT) was then developed as a combination of heterogeneity and intensity (SUVmax range). The SUVmax was less than 15 for score 1, 15-79 with heterogeneous intensity for score 2, 15-79 with homogeneous intensity for score 3, and 80 or greater for score 4. This score was evaluated according to clinical outcomes (PSA50, PSA-PFS, and OS) and compared with SUVmean Results: Data from 139 participants were analyzed. In total, 75 (54%) patients achieved a PSA50 with a median PSA-PFS of 5.5 mo (95% CI, 4.1-6.0 mo) and an OS of 13.5 mo (95% CI, 11.1-17.9 mo). SUVmean was associated with PSA50 and survival outcomes when analyzed as a continuous variable or as quartiles. The PSA50 for HIT scores 1-4 was 0%, 39%, 65%, and 76%, respectively. The HIT score was strongly related to PSA-PFS and OS (log-rank test, P < 0.001 and P = 0.002). The median PSA-PFS for HIT scores 1-4 was 1.0, 4.1, 6.0, and 8.5, respectively, and the median OS was 7.6, 12.0, 18.5, and 16.9 mo, respectively. Cohen κ between readers for the HIT score was 0.71. Conclusion: A prostate-specific membrane antigen PET/CT score incorporating HIT derived from tools on a standard PET workstation is comparable with quantitative SUVmean as a prognostic tool following 177Lu-PSMA therapy.
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Affiliation(s)
- Mina Swiha
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Nuclear Medicine Division, Department of Medical Imaging, University of Western Ontario, London, Ontario, Canada
| | - Nathan Papa
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Zahra Sabahi
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Narjess Ayati
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and
| | - Nikeith John
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and
| | - Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sherrington Li
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Shikha Agrawal
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Adam Hickey
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia;
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia; and
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Kumar S, Crumbaker M, Emmett L. Reply: Unraveling the Hypocalcemic Response to 177Lu-Prostate-Specific Membrane Antigen Therapy. J Nucl Med 2024; 65:333-334. [PMID: 38302158 DOI: 10.2967/jnumed.123.266768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 02/03/2024] Open
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Crumbaker M, Goldstein LD, Murray DH, Tao J, Pathmanandavel S, Boulter N, Ratnayake L, Joshua AM, Kummerfeld S, Emmett L. Circulating Tumour DNA Biomarkers Associated with Outcomes in Metastatic Prostate Cancer Treated with Lutetium-177-PSMA-617. EUR UROL SUPPL 2023; 57:30-36. [PMID: 38020530 PMCID: PMC10658415 DOI: 10.1016/j.euros.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lutetium-177-prostate-specific membrane antigen- 617 (Lu-PSMA) is an effective therapy for metastatic castration-resistant prostate cancer (mCRPC). However, treatment responses are heterogeneous despite stringent positron emission tomography (PET)-based imaging selection criteria. Molecularly based biomarkers have potential to refine patient selection and optimise outcomes. Objective To identify circulating tumour DNA (ctDNA) features associated with treatment outcomes for men treated with Lu-PSMA. Design setting and participants ctDNA from men treated with Lu-PSMA in combination with idronoxil for progressive mCRPC were analysed using an 85-gene customised sequencing assay. ctDNA fractions, molecular profiles, and the presence of alterations in aggressive-variant prostate cancer (AVPC) genes were analysed at baseline, cycle 3 and at disease progression. Intervention Men received Lu-PSMA with idronoxil every 6 wk for up to six cycles. Outcome measurements and statistical analysis Baseline and exit PSMA and fluorodeoxyglucose PET/computed tomography (CT) imaging was conducted at baseline and study exit. Single-photon emission CT (SPECT) scans were performed 24 h after Lu-PSMA. Blood samples were collected at baseline,cycle 3 and at disease progression. Cox proportional-hazards models were used to assess associations and derive hazard ratios (HRs) and confidence intervals (CIs) for associations between molecular factors, imaging features, and clinical outcomes. Results and limitations Sixty samples from 32 men were sequenced (32 at baseline, 24 at cycle 3, four from patients with disease progression); two samples (baseline, on-treatment) from one individual were excluded from analysis owing to poor quality of the baseline sequencing data. Alterations in AVPC genes were associated with shorter prostate-specific antigen (PSA) progression-free survival (PFS) and overall survival (OS) in univariate (HR 3.4, 95% CI 1.5-7.7; p = 0.0036; and HR 3.3, 95% CI 1.4-7.7; p = 0.0063, respectively) and multivariate analyses (HR 4.8, 95% CI 1.8-13; p = 0.0014; and HR 4.1, 95% CI 1.6-11; p = 0.004). Conclusions ctDNA alterations in AVPC genes were associated with shorter PSA PFS and OS among men treated with Lu-PSMA and intermittent idronoxil. These candidate molecular biomarkers warrant further study to determine whether they have predictive value and potential to guide synergistic combination strategies to enhance outcomes for men treated with Lu-PSMA for mCRPC. Patient summary Certain DNA/gene changes detected in the blood of men with advanced prostate cancer were associated with shorter benefit from lutetium PSMA, a targeted radioactive therapy. This information may be useful in determining which men may benefit most from this treatment, but additional research is needed.
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Affiliation(s)
- Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Garvan Institute of Medical Research, Darlinghurst, Australia
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
| | - Leonard D. Goldstein
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - David H. Murray
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Jiang Tao
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Sarennya Pathmanandavel
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
| | - Nicky Boulter
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Lalith Ratnayake
- The Kinghorn Cancer Centre, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
| | - Anthony M. Joshua
- The Kinghorn Cancer Centre, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Sarah Kummerfeld
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Garvan Institute of Medical Research, Darlinghurst, Australia
| | - Louise Emmett
- St. Vincent’s Clinical School, University of New South Wales, Kensington, Australia
- Garvan Institute of Medical Research, Darlinghurst, Australia
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital Sydney, Darlinghurst, Australia
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Kumar S, Crumbaker M, Harvey C, Pathmanandavel S, John N, Swiha MM, McDonald MM, Clifton-Bligh R, Lee A, Bastick P, Counter W, Nguyen A, Emmett L. The Tyr Phenomenon: A Hypocalcemic Response in High-Volume Treatment Responders to 177Lu-Prostate-Specific Membrane Antigen Therapy. J Nucl Med 2023; 64:1412-1416. [PMID: 37348918 DOI: 10.2967/jnumed.123.265759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/10/2023] [Indexed: 06/24/2023] Open
Abstract
177Lu-prostate-specific membrane antigen (PSMA) is an effective treatment for metastatic castration-resistant prostate cancer. Rarer treatment-related adverse events have not yet been described. Methods: We present case reviews of 2 men with a marked hypocalcemic osteosclerotic response to 177Lu-PSMA-I&T therapy. A clinical dataset of 177Lu-PSMA-I&T therapy was evaluated to estimate the incidence and clinical association with hypocalcemia. Results: Forty-one of the 127 men (32%) had a serum calcium drop, and 6 (5%) developed clinical hypocalcemia during 177Lu-PSMA therapy. The baseline total tumor volume was significantly higher in those who developed hypocalcemia (median, 3,249 cm3 [interquartile range, 1,856-3,852] vs. 465 [interquartile range 135-1,172]; P = 0.002). The mean prostate-specific antigen response in those with hypocalcemia was 78% (SD, 24%). Conclusion: Hypocalcemia may occur in response to 177Lu-PSMA-I&T, particularly with both high-volume bone metastases and a significant prostate-specific antigen response, and may be severe, requiring corticosteroids. Further evaluation of 177Lu-PSMA-induced hypocalcemia is required to better understand mechanisms, optimal treatments, and repercussions from any subsequent osteosclerotic response.
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Affiliation(s)
- Shejil Kumar
- Department of Endocrinology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Christopher Harvey
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Nikieth John
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Mina M Swiha
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michelle M McDonald
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- School of Medical Science, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Adrian Lee
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, New South Wales, Australia
- Northern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Genesis Care, Sydney, New South Wales, Australia; and
| | | | - William Counter
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia;
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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John N, Pathmanandavel S, Crumbaker M, Counter W, Ho B, Yam AO, Wilson P, Niman R, Ayers M, Poole A, Hickey A, Agrawal S, Perkins G, Kallinen A, Eslick E, Stockler MR, Joshua AM, Nguyen A, Emmett L. 177Lu-PSMA SPECT Quantitation at 6 Weeks (Dose 2) Predicts Short Progression-Free Survival for Patients Undergoing 177Lu-PSMA-I&T Therapy. J Nucl Med 2023; 64:410-415. [PMID: 36215568 DOI: 10.2967/jnumed.122.264677] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/01/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
177Lu-PSMA is an effective treatment in metastatic castration-resistant prostate cancer (mCRPC). Our ability to assess response rates and adjust treatment may be improved using predictive tools. This study aimed to evaluate change in 177Lu-PSMA SPECT quantitative parameters to monitor treatment response. Methods: One hundred twenty-seven men with progressive mCRPC previously treated with androgen-signaling inhibition (99%) and chemotherapy (71%) received a median of 3 (interquartile range [IQR], 2-5) 8-GBq (IQR, 8-8.5 GBq) doses of 177Lu-PSMA-I&T. Imaging included 68Ga-PSMA-11 PET/CT (SUVmax > 15 at a single site and > 10 at all sites > 2 cm), diagnostic CT, and 177Lu SPECT/CT from vertex to mid thigh (24 h after treatment). 177Lu SPECT/CT quantitative analysis was undertaken at cycles 1 (baseline) and 2 (week 6) of treatment. Clinical and biochemical results were assessed to evaluate prostate-specific antigen (PSA) progression-free survival (PFS) and overall survival (OS). Results: A PSA reduction of more than 50% was seen in 58% (74/127). The median PSA PFS was 6.1 mo (95% CI, 5.5-6.7), and OS was 16.8 mo (95% CI, 13.5-20.1). At the time of analysis, 41% (52/127) were deceased. At baseline and week 6, 76% (96/127) had analyzable serial 177Lu SPECT/CT imaging. SPECT total tumor volume (TTV) was reduced between baseline and week 6 in 74% (71/96; median, -193; IQR, -486 to -41). Any increase in SPECT TTV between baseline and week 6 was associated with significantly shorter PSA PFS (hazard ratio, 2.5; 95% CI, 1.5-4.2; P = 0.0008) but not OS. Median PSA PFS in those with an increase in SPECT TTV was 3.7 mo (95% CI, 2.8-6.8), compared with 6.7 mo (95% CI, 5.8-10.6) in those with no increase in SPECT TTV. An increase in SPECT TTV greater than 20% was also associated with PSA PFS (hazard ratio, 1.9; 95% CI, 1.2-3.0; P = 0.008) but less significantly than any change in SPECT TTV. There was a significant difference in PSA PFS between patients with both increased PSA and SPECT TTV and patients with reduced SPECT TTV and PSA (median, 2.8 vs. 9.0 mo; P < 0.0001). Conclusion: Increasing PSMA SPECT TTV on quantitative 177Lu SPECT/CT predicts short progression-free survival and may play a future role as an imaging response biomarker, identifying when to cease or intensify 177Lu-PSMA therapy.
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Affiliation(s)
- Nikeith John
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - William Counter
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Bao Ho
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew O Yam
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | | | - Remy Niman
- MIM Software, Inc., Cleveland, Ohio; and
| | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Aron Poole
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Adam Hickey
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Shikha Agrawal
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Gary Perkins
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Annukka Kallinen
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Enid Eslick
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony M Joshua
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia;
- St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
- Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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7
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Pemberton L, Allen C, Handel E, Weickhardt AJ, Tran B, Crumbaker M, Shapiro JD, Risbridger GP, Pook DW. Carboplatin in metastatic castrate resistant prostate cancer: A retrospective study of heavily pretreated patients (COMPACT). J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.6_suppl.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/15/2023] Open
Abstract
158 Background: Despite a lack of up-to-date clinical trial data, many clinicians advocate the use of Carboplatin monotherapy to treat patients with advanced Castrate Resistant Prostate Cancer (CRPC) who have exhausted multiple other treatment options. The aim of this study was to determine the overall survival (OS) and response rate in patients with advanced CRPC treated with Carboplatin monotherapy after progressing on other chemotherapy agents. Methods: Retrospective multicentre study of the use of Carboplatin in advanced CRPC patients in Australia. Demographic data, PSA response rates, survival data and Carboplatin treatment protocols, such as dose and duration, were collected. Exploratory analyses on potential prognostic parameters were performed. Results: 51 patients received Carboplatin: median age 68 (range 55–86 years). Most patients (78.3%) received Carboplatin AUC 5 at 3-weekly intervals. The median number of cycles of Carboplatin was 3 (range 1-17). Median time on treatment was 63 days (range 1-441). Median overall survival was 29.4 weeks (IQR 11.7 weeks). 6 (11.8%) patients had a PSA response ≥50%. The median time to PSA progression on Carboplatin was 67 days (range 15-418). 16 patients (31%) required a dose delay or reduction and 8 patients (15.6%) ceased Carboplatin secondary to side effects/ toxicity. Conclusions: Our findings demonstrate that in heavily pre-treated CRPC, Carboplatin has a modest benefit in a minority of patients with a low rate of toxicity in the advanced prostate cancer population.
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Affiliation(s)
- Lara Pemberton
- Prostate Cancer Research Program, Monash University, Melbourne, VIC, Australia
| | | | | | - Andrew James Weickhardt
- Olivia Newton-John Cancer Wellness & Research Centre, Austin Health, Melbourne, VIC, Australia
| | - Ben Tran
- Peter MacCallum Cancer Centre and Walter and Eliza Hall Institute, Melbourne, Australia
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8
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Pathmanandavel S, Crumbaker M, Ho B, Yam AO, Wilson P, Niman R, Ayers M, Sharma S, Hickey A, Eu P, Stockler M, Martin AJ, Joshua AM, Nguyen A, Emmett L. Evaluation of 177Lu-PSMA-617 SPECT/CT Quantitation as a Response Biomarker Within a Prospective 177Lu-PSMA-617 and NOX66 Combination Trial (LuPIN). J Nucl Med 2023; 64:221-226. [PMID: 36008120 PMCID: PMC9902857 DOI: 10.2967/jnumed.122.264398] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/22/2022] [Accepted: 07/22/2022] [Indexed: 02/04/2023] Open
Abstract
177Lu-PSMA-617 is an effective and novel treatment in metastatic castration-resistant prostate cancer (mCRPC). Our ability to assess response rates and therefore efficacy may be improved using predictive tools. This study investigated the predictive value of serial 177Lu-PSMA-617 SPECT/CT (177Lu SPECT) imaging in monitoring treatment response. Methods: Fifty-six men with progressive mCRPC previously treated with chemotherapy and novel androgen signaling inhibitor were enrolled into the LuPIN trial and received up to 6 doses of 177Lu-PSMA-617 and a radiation sensitizer (3-(4-hydroxyphenyl)-2H-1-benzopyran-7-ol [NOX66]). 68Ga-PSMA-11 and 18F-FDG PET/CT were performed at study entry and exit, and 177Lu SPECT from vertex to mid thighs was performed 24 h after each treatment. SPECT quantitative analysis was undertaken at cycles 1 (baseline) and 3 (week 12) of treatment. Results: Thirty-two of the 56 men had analyzable serial 177Lu SPECT imaging at both cycle 1 and cycle 3. In this subgroup, median prostate-specific antigen (PSA) progression-free survival (PFS) was 6.3 mo (95% CI, 5-10 mo) and median overall survival was 12.3 mo (95% CI, 12-24 mo). The PSA 50% response rate was 63% (20/32). 177Lu SPECT total tumor volume (SPECT TTV) was reduced in 68% (22/32; median, -0.20 m3 [95% CI, -1.4 to -0.001]) and increased in 31% (10/32; median, 0.36 [95% CI, 0.1-1.4]). Any increase in SPECT TTV was associated with shorter PSA PFS (hazard ratio, 4.1 [95% CI, 1.5-11.2]; P = 0.006). An increase of 30% or more in SPECT TTV was also associated with a shorter PSA PFS (hazard ratio, 3.3 [95% CI, 1.3-8.6]; P =0.02). Tumoral SUVmax was reduced in 91% (29/32) and SUVmean in 84% (27/32); neither was associated with PSA PFS or overall survival outcomes. PSA progression by week 12 was also associated with a shorter PSA PFS (hazard ratio, 26.5 [95% CI, 5.4-131]). In the patients with SPECT TTV progression at week 12, 50% (5/10) had no concurrent PSA progression (median PSA PFS, 4.5 mo [95% CI, 2.8-5.6 mo]), and 5 of 10 men had both PSA and SPECT TTV progression at week 12 (median PSA PFS, 2.8 mo [95% CI, 1.8-3.7 mo]). Conclusion: Increasing SPECT TTV on quantitative 177Lu SPECT predicts a short PFS and may play a future role as an imaging response biomarker.
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Affiliation(s)
- Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Bao Ho
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Andrew O. Yam
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Adam Hickey
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; and
| | - Martin Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Andrew J. Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia; .,Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, New South Wales, Australia
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9
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Emmett L, John N, Pathmanandavel S, Counter W, Ayers M, Sharma S, Agrawal S, Poole A, Hovey E, Pranavan G, Gedye C, Mallesara G, Guminski A, Lee A, Stockler MR, Hickey A, Eu P, Joshua AM, Crumbaker M, Nguyen A. Patient outcomes following a response biomarker-guided approach to treatment using 177Lu-PSMA-I&T in men with metastatic castrate-resistant prostate cancer (Re-SPECT). Ther Adv Med Oncol 2023; 15:17588359231156392. [PMID: 36872949 PMCID: PMC9983078 DOI: 10.1177/17588359231156392] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/25/2023] [Indexed: 03/06/2023] Open
Abstract
Background 177LuPSMA is an effective treatment in metastatic castrate-resistant prostate cancer with trials adopting a standardised dose interval. Adjusting treatment intervals utilising early response biomarkers may improve patient outcomes. Objective This study evaluated progression-free survival (PFS) and overall survival (OS) based on treatment interval adjustment utilising 177LuPSMA 24-h SPECT/CT (177Lu-SPECT) and early prostate-specific antigen (PSA) response. Design Retrospective analysis of a clinical 177Lu-PSMA-I&T treatment programme. Methods In all, 125 men were treated with 6-weekly 177LuPSMA-I&T [median 3 cycles, interquartile range (IQR): 2-4], median dose 8.0 GBq [95% confidence interval (CI): 7.5-8.0]. Imaging screening involved 68GaPSMA-11 PET/diagnostic CT. 177Lu-SPECT/diagnostic CT was acquired following each therapy, and clinical assessments 3-weekly. Following dose 2 (week 6), a composite PSA and 177Lu-SPECT/CT imaging response [partial response (PR), stable disease (SD), and progressive disease (PD)] determined ongoing management. Response group (RG) 1 (marked reduction in PSA/imaging PR) break in treatment until subsequent PSA rise, then re-treatment. RG 2 (stable or reduced PSA and/or imaging SD) 6-weekly treatments until six doses, or no longer clinically benefitting. RG 3 (rise in PSA and/or imaging PD) recommended for an alternative treatment. Results Overall PSA50% response rate (PSARR) was 60% (75/125), median PSA-PFS 6.1 months (95%CI: 5.5-6.7), and median OS 16.8 months (95%CI: 13.5-20.1). 35% (41/116) were classified as RG 1, 34% (39/116) RG 2, and 31% (36/116) RG 3. PSARRs by RG were 95% (38/41), 74% (29/39), and 8% (3/36); median PSA-PFS rates were 12.1 months (95%CI: 9.3-17.4), 6.1 months (95%CI: 5.8-9.0), and 2.6 months (95%CI: 1.6-3.1); and OS rates were 19.2 months (95%CI: 16.8-20.7), 13.2 months (95%CI: 12.0-18.8), and 11.2 months (95%CI: 8.7-15.6) for RG 1, 2, and 3, respectively. The median months of 'treatment holiday' for RG 1 was 6.1 months (IQR: 3.4-8.7). Nine men had received prior 177LuPSMA-617 and were retreated with 177LuPSMA-I&T, with a PSARR of 56% on re-treatment. Conclusion Personalising dosing regimens using early response biomarkers with 177LuPSMA has the potential to achieve similar treatment responses to continuous dosing while allowing treatment breaks or intensification. Further evaluation of early response biomarker-guided treatment regimens in prospective trials is warranted. Plain Language Summary Lutetium-PSMA therapy is a new therapy for metastatic prostate cancer that is well tolerated and effective. However, not all men respond equally, with some responding very well and others progressing early. Personalising treatments require tools that can accurately measure treatment responses, preferably early in the treatment course, so adjustments to treatment can be made. Lutetium-PSMA can measure tumour sites after each therapy by taking whole body 3D images at 24 h using a small radiation wave from the treatment itself. This is called a SPECT scan. Previous work has shown that both prostate-specific antigen (PSA) response and changes in tumour volume on a SPECT scan can predict how patients will respond to treatment as early as dose 2. This study demonstrates that stratifying how men are treated based on the results of the 6-week SPECT scan and PSA response potentially allows a third of men to have break in treatment and that these men have both longer time to disease progression and OS. Men with an increase in tumour volume and increase in PSA early in treatment (6 weeks) had shorter time to disease progression and OS. Men with early biomarker disease progression were offered alternative treatments early in an attempt to allow the opportunity to allow a more effective potential therapy, if one was available. The study is an analysis of a clinical programme, and was not a prospective trial. As such, there are potential biases that could influence results. Hence, while the study is encouraging for the use of early response biomarkers to guide better treatment decisions, this must be validated in a well-designed clinical trial.
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, 390 Victoria Street, Sydney, NSW 2010, Australia.,Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Nikeith John
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - William Counter
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Shikha Agrawal
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Aron Poole
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Elizabeth Hovey
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.,Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Ganes Pranavan
- Department of Medical Oncology, The Canberra Hospital, Garran, ACT, Australia
| | - Craig Gedye
- Calvary Mater Hospital, Newcastle, NSW, Australia
| | | | - Alex Guminski
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Adrian Lee
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Adam Hickey
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Peter Eu
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia
| | - Anthony M Joshua
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Megan Crumbaker
- Garvan Institute of Medical Research, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,St. Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
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10
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Pathmanandavel S, Crumbaker M, Nguyen A, Yam AO, Wilson P, Niman R, Ayers M, Sharma S, Eu P, Martin AJ, Stockler MR, Joshua AM, Emmett L. The Prognostic Value of Posttreatment 68Ga-PSMA-11 PET/CT and 18F-FDG PET/CT in Metastatic Castration-Resistant Prostate Cancer Treated with 177Lu-PSMA-617 and NOX66 in a Phase I/II Trial (LuPIN). J Nucl Med 2023; 64:69-74. [PMID: 35738906 PMCID: PMC9841258 DOI: 10.2967/jnumed.122.264104] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 06/13/2022] [Accepted: 06/13/2022] [Indexed: 01/28/2023] Open
Abstract
177Lu-PSMA-617 therapy has shown high prostate-specific antigen (PSA) response rates in men with metastatic castration-resistant prostate cancer. However, early treatment resistance is common. This LuPIN substudy aimed to determine the prognostic value of posttreatment quantitative PET for PSA progression-free survival (PFS) and overall survival (OS) with 177Lu-PSMA-617 therapy. Methods: Fifty-six men with progressive metastatic castration-resistant prostate cancer were enrolled in the LuPIN trial and received up to 6 doses of 177Lu-PSMA-617 and a radiation sensitizer (NOX66). 68Ga-PSMA-11 and 18F-FDG PET/CT, diagnostic CT, and bone scanning were performed at study entry and exit. Quantitative analysis tracked change in total tumor volume (TTV) and SUV. Univariable and multivariable analyses were conducted to examine the association of change in TTV (continuous and >30%), SUVmax, PSA, and radiographic progression with PSA PFS and OS. Results: All men (37/56) who underwent both screening and posttreatment molecular imaging were analyzed; 70% (26/37) had a PSA response of more than 50%. Median PSA PFS was 8.6 mo, and median OS was 22 mo. Clinical progression had occurred at trial exit in 54% (20/37). In response to treatment, a reduced PSMA SUVmax was demonstrated in 95% (35/37) and a reduced PSMA TTV in 68% (25/37). An increase in PSMA TTV by at least 30% was associated with worse OS (median, 10.2 vs. 23.6 mo; P = 0.002). Change in PSMA SUVmax was not associated with PSA PFS or OS. 18F-FDG SUVmax was reduced in 51% (18/35) and 18F-FDG TTV in 67% (22/35). An increased 18F-FDG SUVmax was associated with worse OS (median, 20.7 vs. 25.7 mo; P < 0.01). An 18F-FDG TTV increase by more than 30% was associated with a short PSA PFS (median, 3.5 vs. 8.6 mo; P < 0.001) but not OS. Both PSA and radiographic progression were associated with shorter OS (median, 14.5 vs. 25.7 mo [P < 0.001] and 12.2 vs. 23.6 mo [P = 0.002]). On multivariable analysis, only increased PSMA TTV and PSA progression remained independently prognostic of OS (hazard ratio, 5.1 [95% CI, 1.5-17.1; P = 0.008] and 3.5 [95% CI, 1.1-10.9; P = 0.03], respectively). Conclusion: Change in quantitative PSMA TTV has strong potential as a prognostic biomarker with 177Lu-PSMA-617 therapy, independent of 18F-FDG PET parameters, PSA, or radiographic progression. Further research into the value of posttreatment PET as an imaging biomarker is warranted.
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Affiliation(s)
- Sarennya Pathmanandavel
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, New South Wales, Australia; .,Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, New South Wales, Australia.,Garvan Institute of Medical Research, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew O. Yam
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | | | | | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew J. Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; and
| | - Martin R. Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, New South Wales, Australia; and
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia;,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent’s Hospital, Sydney, New South Wales, Australia;,Garvan Institute of Medical Research, Sydney, New South Wales, Australia;,St. Vincent’s Clinical School, University of New South Wales, Sydney, New South Wales, Australia;,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
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11
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Joshua AM, Armstrong A, Crumbaker M, Scher HI, de Bono J, Tombal B, Hussain M, Sternberg CN, Gillessen S, Carles J, Fizazi K, Lin P, Duggan W, Sugg J, Russell D, Beer TM. Statin and metformin use and outcomes in patients with castration-resistant prostate cancer treated with enzalutamide: A meta-analysis of AFFIRM, PREVAIL and PROSPER. Eur J Cancer 2022; 170:285-295. [PMID: 35643841 PMCID: PMC10394474 DOI: 10.1016/j.ejca.2022.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Statins and metformin are commonly prescribed for patients, including those with prostate cancer. Preclinical and epidemiologic studies of each agent have suggested anti-cancer properties. METHODS Patient data from three randomised, double-blind, placebo-controlled, phase III studies evaluating enzalutamide (AFFIRM, PREVAIL and PROSPER) in patients with castration-resistant prostate cancer were included in this analysis. This post hoc, retrospective study examined the association of statin and metformin on radiographic progression-free survival (rPFS), metastasis-free survival (MFS), toxicity and overall survival (OS). After adjusting for available clinical prognostic variables, multivariate analyses were performed on pooled data from AFFIRM and PREVAIL, all three trials pooled, and each trial individually, to assess differential efficacy in these end-points associated with the baseline use of these medications. RESULTS In the multivariate analysis of the individual trials, OS and rPFS/MFS were not significantly influenced by statin or metformin use in AFFIRM or PROSPER. However, in PREVAIL, OS was significantly influenced by statin (hazard ratio [HR] 0.72; 95% confidence interval [CI] 0.59-0.89) and rPFS was significantly influenced by metformin (HR, 0.48; 95% CI 0.34-0.70). In pooled analyses, improved OS was significantly associated with statin use but not metformin use for AFFIRM+PREVAIL trials (HR 0.83; 95% CI 0.72-0.96) and AFFIRM+PREVAIL+PROSPER (HR 0.75; 95% CI 0.66-0.85). CONCLUSIONS The association between statin or metformin use and rPFS, MFS and OS was inconsistent across three trials. Analyses of all three trials pooled and AFFIRM+PREVAIL pooled revealed that statin but not metformin use was significantly associated with a reduced risk of death in enzalutamide-treated patients. Additional prospective, controlled studies are warranted. CLINICAL TRIAL REGISTRATION AFFIRM (NCT00974311), PREVAIL (NCT01212991) and PROSPER (NCT02003924).
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Affiliation(s)
- Anthony M Joshua
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, NSW, Australia.
| | - Andrew Armstrong
- Duke Cancer Institute Center for Prostate and Urologic Cancers, Duke University, Durham, NC, USA
| | - Megan Crumbaker
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Howard I Scher
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Johann de Bono
- The Institute of Cancer Research and the Royal Marsden NHS Foundation Trust, London, UK
| | | | - Maha Hussain
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
| | - Cora N Sternberg
- Englander Institute for Precision Medicine, Weill Cornell Medicine, Meyer Cancer Center, New York, NY, USA
| | - Silke Gillessen
- Oncology Institute of Southern Switzerland, EOC, Bellinzona, Switzerland
| | - Joan Carles
- Vall D'Hebron University Hospital, Vall D'Hebron Institute of Oncology (VHIO), Barcelona, Spain
| | - Karim Fizazi
- Institut Gustave Roussy, University of Paris Saclay, Villejuif, France
| | - Ping Lin
- Formerly of Pfizer Inc., San Francisco, CA, USA
| | | | | | | | - Tomasz M Beer
- OHSU Knight Cancer Institute, Oregon Health & Science University, Portland, OR, USA
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Hamid A, Hofman MS, Bressel M, Emmett L, Joshua AM, Spain LA, Horvath L, Crumbaker M, Pasam A, Callahan J, Tubbs A, Fernandez L, Wenstrup RJ, Kong G, Lewin JH, Tran B, Azad A, Schonhoft JD, Hicks RJ, Sandhu S. Circulating tumour cells (CTCs) and PSMA PET correlates in the phase I PRINCE trial of 177Lu-PSMA-617 plus pembrolizumab for metastatic castration resistant prostate cancer (mCRPC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5027 Background: The Phase I PRINCE trial (NCT03658447) is evaluating the efficacy of 177Lu-PSMA-617 plus pembrolizumab for mCRPC. The utility of serial monitoring of CTCs and PET as biomarkers of prognosis and clinical benefit of 177Lu-PSMA-617-based therapy remains unknown. Methods: 36 of 37 pts with high PSMA expression on PSMA PET underwent serial CTC collections in conjunction with PSMA PET at baseline, every 12 weeks for 48 weeks and every 24 weeks thereafter. CK+, CD45- CTCs were enumerated from 3ml of blood and stained for PSMA (Epic Sciences platform). Associations between PSMA+ CTC counts, PET molecular tumor volume (MTV), total lesional activity (TLA; MTVxSUVmean) were assessed by Spearman correlation. Cox models assessed the association of CTC and PSMA PET parameters with radiographic progression-free survival (rPFS) and PSA PFS. A subset of pre-treatment CTCs underwent single cell low-pass whole genome sequencing to characterize copy number aberrations. Results: 32/36 pt (89%) had detectable CTCs (median 7, range 0-514) with 23 (64%) being PSMA+ (median 1, range 0-224) at baseline. At w12, 23/33 (70%) had CTCs detected with 10 (30%) being PSMA+. Baseline PSMA+ CTC count and MTV were moderately correlated (rs= 0.57, p < 0.001). Of 22 evaluable pts with baseline PSMA+ CTC, 18 (82%) showed decrease by w12 with clearance in 13. This paralleled reductions in MTV (-18% med relative change, IQR: -57 to -1) and TLA (-48% med relative change, IQR: -77 to -28). Total CTC and PSMA+ CTC counts at baseline, and PET parameters were not associated with PSA PFS or rPFS. Clearance of PSMA+ CTC by w12 (13/22 pts) was associated with improved rPFS (med NR vs 3.0 mos, HR 0.23, 95%CI 0.07-0.74, p = 0.007) and PSA PFS (med 11.2 vs 3.5 mos, HR 0.28, 95%CI 0.11-0.73, p = 0.006). Persisting PSMA-neg CTCs at w12 trended to worse rPFS (med 4.1 vs 12.3 mos, p = 0.11) and PSA PFS (med 5.1 vs 12.3 mos, p = 0.07). Of pts not progressing by w12, decrease in PSA (HR 0.83 per 10% decrease, 95%CI 0.74-0.93, p < 0.001), MTV (HR 0.85 per 10% decrease, 95%CI 0.75-0.96, p = 0.008), MTV > 30% decrease (HR 0.30, 95% CI 0.08-1.08, p = 0.05) and TLA (HR 0.88 per 10% decrease, 95%CI 0.78-1.00, p = 0.04) associated with improved rPFS beyond w12. Pre-treatment CTCs (18 pts) exhibited genomic heterogeneity and frequent loss of PTEN, TP53 and RB1. Pts with compound TP53 and RB1 loss at baseline nonetheless had PSMA+ CTCs in high proportion (med 91.3% of total CTCs). Conclusions: PSMA PET-positive mCRPC is associated with high rates of PSMA+ CTCs which decline with 177Lu-PSMA-617 plus pembrolizumab in parallel with PSMA MTV/TLA. Despite imaging suitability for therapy, CTCs had heterogenous PSMA expression and genomic alterations associated with aggressive disease. Early changes in PSMA+ CTCs and MTV/TLA were associated with outcomes and may aid in determining clinical activity of LuPSMA-based therapy.
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Affiliation(s)
- Anis Hamid
- Eastern Health and University of Melbourne, Melbourne, Australia
| | - Michael S Hofman
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, NSW, Australia
| | | | | | | | | | | | | | | | | | - Grace Kong
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Jeremy Howard Lewin
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Ben Tran
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Arun Azad
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Rodney J. Hicks
- St. Vincent's Medical School, University of Melbourne, Melbourne, Australia
| | - Shahneen Sandhu
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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13
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Sandhu S, Joshua AM, Emmett L, Spain LA, Horvath L, Crumbaker M, Anton A, Wallace R, Pasam A, Bressel M, Cassidy E, Banks P, Dhiantravan N, Akhurst TJ, Ravi Kumar A, Alipour R, Scalzo M, Williams S, Hicks R, Hofman MS. PRINCE: Phase I trial of 177Lu-PSMA-617 in combination with pembrolizumab in patients with metastatic castration-resistant prostate cancer (mCRPC). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.16_suppl.5017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5017 Background: The VISION and TheraP trials have established the safety and efficacy of 177Lu-PSMA-617 in mCRPC with a 50% PSA response rate (PSA50-RR) of 46% and 66% and median progression free survival (PFS) of 8.7 and 5.1 months, respectively. More effective treatments are required as disease progression remains universal. Immunotherapy has limited single-agent efficacy in mCRPC. We hypothesise that by potentially inducing immunogenic cell death, 177Lu-PSMA-617 may act synergistically with pembrolizumab, an anti-programmed death 1 inhibitor, to enhance the depth and durability of response. PRINCE is a Phase I trial evaluating the safety and efficacy of this combination. Methods: mCRPC patients with high PSMA expression (SUVmax ≥ 20 in an index lesion, SUVmax > 10 for all lesions ≥ 10mm), and no FDG+ve/PSMA-ve lesions on paired baseline PET/CT screening, received up to 6 cycles of 177Lu-PSMA-617 (starting at 8.5 GBq, reducing by 0.5 GBq with each cycle) every 6 weeks in conjunction with 200mg of pembrolizumab every 3 weeks for up to 2 years. Response evaluation was undertaken as per PCWG3 and RECIST criteria. Co-primary endpoints were safety and PSA50-RR. Secondary endpoints included PSA-PFS, radiographic PFS (rPFS), overall survival (OS), and patient reported outcomes (PROs). This analysis was undertaken after the last patient had 12 months follow-up. Results: 37 patients (median age 72 years; prior docetaxel 73%; prior androgen receptor targeted agent 100%) received a median of 5 cycles (range: 2 to 6) of 177Lu-PSMA-617 and 12 doses (range: 6 to 19) of pembrolizumab. The median follow up was 16 months. PSA50-RR was 76% (28/37 [95% CI 59-88]) and 7/10 (70%) patients with RECIST-measurable disease had a partial response. Median rPFS, PSA-PFS and OS was 11.2 months (95% CI: 5.1-14.1), 8.2 months (95% CI: 5.1-11.2) and 17.8 months (95% CI:13.4-not estimable). 12-month rPFS and OS was 38% (95% CI: 22-54) and 83% (95% CI: 67-92), respectively. Common (≥10%) treatment-related adverse events (TRAE) were mainly Grade (G) 1-2, including xerostomia (78%), fatigue (43%), pruritus (27%), nausea (27%), rash (24%), diarrhoea (14%), anorexia (16%), thrombocytopenia (16%), elevated ALT (11%), arthralgia (11%) and a flare in bone pain (11%). Haematologic TRAEs included G2-3 anaemia (8%), G1-2 thrombocytopenia (16%), and G1 neutropenia (3%). G3 immune-related AEs occurred in 10 (27%) patients with no dominant manifestation. 5 (14%) patients discontinued pembrolizumab due to toxicity. PROs including BPI-SF and FACT-P were stable throughout the study. Conclusions: The combination of 177Lu-PSMA-617 and pembrolizumab had promising activity. Toxicities were generally consistent with those of single-agent 177Lu-PSMA-617 and pembrolizumab and were not clearly augmented by combination use. No new safety concerns were observed. Clinical trial information: NCT03658447.
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Affiliation(s)
- Shahneen Sandhu
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | | | | | | | | | | | | | - Roslyn Wallace
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Erin Cassidy
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Patricia Banks
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | | | | | | | | | - Mark Scalzo
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Scott Williams
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
| | - Rodney Hicks
- St. Vincent’s Medical School, University of Melbourne, Melbourne, Australia
| | - Michael S Hofman
- Peter MacCallum Cancer Centre and Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, VIC, Australia
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14
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Conduit C, Mak B, Qu W, Lulio JD, Burder R, Bressel M, Cusick T, Dhillon HM, Lourenço RDA, Underhill C, Torres J, Crumbaker M, Honeyball F, Linton A, Allen R, Davis ID, Clark SJ, Horvath LG, Mahon KL. GUIDE: a randomised non-comparative phase II trial of biomarker-driven intermittent docetaxel versus standard-of-care docetaxel in metastatic castration-resistant prostate cancer (clinical trial protocol). Ther Adv Med Oncol 2022; 14:17588359221092486. [PMID: 35465297 PMCID: PMC9019311 DOI: 10.1177/17588359221092486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022] Open
Abstract
Objective: To determine the efficacy and safety of intermittent docetaxel chemotherapy guided by circulating methylated glutathione S-transferase Pi-1 (mGSTP1) in men with metastatic castration-resistant prostate cancer (CRPC). Patients and Methods: GUIDE (NCT04918810) is a randomised, two-arm, non-comparative phase-2 trial recruiting 120 patients at six Australian centres. Patients with Prostate Cancer Working Group-3 defined metastatic CRPC who are commencing docetaxel 75 mg/m2 q3w will be pre-screened for detectable mGSTP1 at baseline ± following two cycles of treatment. Those with detectable plasma mGSTP1 at baseline that becomes undetectable after two cycles of chemotherapy will be eligible for GUIDE. Prior to Cycle 4 of docetaxel, these patients are randomised 2:1 to one of two treatment arms: Arm A (cease docetaxel and reinstitute if mGSTP1 becomes detectable) or Arm B (continue docetaxel 75 mg/m2 q3w in accordance with clinician’s usual practice). The primary endpoint is radiographic progression-free survival. Secondary endpoints include time on treatment holidays, safety, patient-reported outcomes, overall survival, health resource use, and cost associated with treatment. Enrolment commenced November 2021. Results and Conclusion: The results of this trial will generate data on the clinical utility of mGSTP1 as a novel biomarker to guide treatment de-escalation in metastatic CRPC.
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Affiliation(s)
- Ciara Conduit
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia Personalised Oncology, Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Blossom Mak
- Chris O’Brien Lifehouse, Camperdown, NSW, Australia Garvan Institute of Medical Research, Darlinghurst, NSW, Australia The University of Sydney, Sydney, NSW, Australia
| | - Wenjia Qu
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Juliana Di Lulio
- Centre for Biostatistics and Clinical Trials (BaCT), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Ronan Burder
- Centre for Biostatistics and Clinical Trials (BaCT), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Matthias Bressel
- Centre for Biostatistics and Clinical Trials (BaCT), Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Thomas Cusick
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Haryana M. Dhillon
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia Centre for Medical Psychology and Evidence-Based Decision-Making, School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia Psycho-Oncology Cooperative Research Group, School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Richard De Abreu Lourenço
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, NSW, Australia
| | - Craig Underhill
- Border Medical Oncology Research Unit, Albury Wodonga Regional Cancer Centre, Albury, NSW, Australia University of NSW Rural Clinical School, Albury, NSW, Australia
| | - Javier Torres
- Goulburn Valley Health, Shepparton, VIC, Australia Rural Medical School, The University of Melbourne, Shepparton, VIC, Australia
| | - Megan Crumbaker
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia St. Vincent’s Clinical School, University of New South Wales, Sydney, NSW, Australia The Kinghorn Cancer Centre, St. Vincent’s Hospital Sydney, Darlinghurst, NSW, Australia
| | - Florian Honeyball
- Dubbo Base Hospital, Dubbo, NSW, Australia School of Rural Health, The University of Sydney, Dubbo, NSW, Australia
| | - Anthony Linton
- The University of Sydney, Sydney, NSW, Australia Concord Cancer Centre, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Ray Allen
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia
| | - Ian D. Davis
- Australian and New Zealand Urogenital and Prostate (ANZUP) Cancer Trials Group, Camperdown, NSW, Australia Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia Eastern Health, Box Hill, VIC, Australia
| | - Susan J. Clark
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia UNSW Sydney, Sydney, NSW, Australia
| | - Lisa G. Horvath
- Chris O’Brien Lifehouse, Camperdown, NSW, Australia Garvan Institute of Medical Research, Darlinghurst, Sydney, NSW, Australia The University of Sydney, Sydney, NSW, Australia Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Kate L. Mahon
- Chris O’Brien Lifehouse, 119-143 Missenden Rd, Camperdown, NSW 2050, Australia
- Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
- The University of Sydney, Sydney, NSW, AustraliaRoyal Prince Alfred Hospital, Camperdown, NSW, Australia
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15
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Mak B, Lin HM, Kwan EM, Fettke H, Tran B, Davis ID, Mahon K, Stockler MR, Briscoe K, Marx G, Zhang A, Crumbaker M, Tan W, Huynh K, Meikle TG, Mellett NA, Hoy AJ, Du P, Yu J, Jia S, Joshua AM, Waugh DJ, Butler LM, Kohli M, Meikle PJ, Azad AA, Horvath LG. Combined impact of lipidomic and genetic aberrations on clinical outcomes in metastatic castration-resistant prostate cancer. BMC Med 2022; 20:112. [PMID: 35331214 PMCID: PMC8953070 DOI: 10.1186/s12916-022-02298-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/14/2022] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Both changes in circulating lipids represented by a validated poor prognostic 3-lipid signature (3LS) and somatic tumour genetic aberrations are individually associated with worse clinical outcomes in men with metastatic castration-resistant prostate cancer (mCRPC). A key question is how the lipid environment and the cancer genome are interrelated in order to exploit this therapeutically. We assessed the association between the poor prognostic 3-lipid signature (3LS), somatic genetic aberrations and clinical outcomes in mCRPC. METHODS We performed plasma lipidomic analysis and cell-free DNA (cfDNA) sequencing on 106 men with mCRPC commencing docetaxel, cabazitaxel, abiraterone or enzalutamide (discovery cohort) and 94 men with mCRPC commencing docetaxel (validation cohort). Differences in lipid levels between men ± somatic genetic aberrations were assessed with t-tests. Associations between the 3LS and genetic aberrations with overall survival (OS) were examined using Kaplan-Meier methods and Cox proportional hazard models. RESULTS The 3LS was associated with shorter OS in the discovery (hazard ratio [HR] 2.15, 95% confidence interval [CI] 1.4-3.3, p < 0.001) and validation cohorts (HR 2.32, 95% CI 1.59-3.38, p < 0.001). Elevated plasma sphingolipids were associated with AR, TP53, RB1 and PI3K aberrations (p < 0.05). Men with both the 3LS and aberrations in AR, TP53, RB1 or PI3K had shorter OS than men with neither in both cohorts (p ≤ 0.001). The presence of 3LS and/or genetic aberration was independently associated with shorter OS for men with AR, TP53, RB1 and PI3K aberrations (p < 0.02). Furthermore, aggressive-variant prostate cancer (AVPC), defined as 2 or more aberrations in TP53, RB1 and/or PTEN, was associated with elevated sphingolipids. The combination of AVPC and 3LS predicted for a median survival of ~12 months. The relatively small sample size of the cohorts limits clinical applicability and warrants future studies. CONCLUSIONS Elevated circulating sphingolipids were associated with AR, TP53, RB1, PI3K and AVPC aberrations in mCRPC, and the combination of lipid and genetic abnormalities conferred a worse prognosis. These findings suggest that certain genotypes in mCRPC may benefit from metabolic therapies.
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Affiliation(s)
- Blossom Mak
- Chris O'Brien Lifehouse, Missenden Rd, Camperdown, New South Wales, 2050, Australia.,Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia
| | - Hui-Ming Lin
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia.,St Vincent's Clinical School, UNSW, Sydney, New South Wales, Australia
| | | | - Heidi Fettke
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ben Tran
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Ian D Davis
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia.,Eastern Health, Box Hill, Victoria, Australia
| | - Kate Mahon
- Chris O'Brien Lifehouse, Missenden Rd, Camperdown, New South Wales, 2050, Australia.,Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia.,University of Sydney, Sydney, New South Wales, Australia.,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Martin R Stockler
- University of Sydney, Sydney, New South Wales, Australia.,Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Karen Briscoe
- Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Gavin Marx
- Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Alison Zhang
- Chris O'Brien Lifehouse, Missenden Rd, Camperdown, New South Wales, 2050, Australia
| | - Megan Crumbaker
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia.,The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | | | - Kevin Huynh
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas G Meikle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Andrew J Hoy
- School of Medical Sciences, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Pan Du
- Predicine, Inc., Hayward, CA, USA
| | | | | | - Anthony M Joshua
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia.,St Vincent's Clinical School, UNSW, Sydney, New South Wales, Australia.,The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - David J Waugh
- Queensland University of Technology, Brisbane, Queensland, Australia
| | - Lisa M Butler
- Adelaide Medical School and Freemason's Foundation Centre for Men's Health, University of Adelaide, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Manish Kohli
- Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Arun A Azad
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Lisa G Horvath
- Chris O'Brien Lifehouse, Missenden Rd, Camperdown, New South Wales, 2050, Australia. .,Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia. .,University of Sydney, Sydney, New South Wales, Australia. .,St Vincent's Clinical School, UNSW, Sydney, New South Wales, Australia. .,Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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16
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Pathmanandavel S, Crumbaker M, Yam AO, Nguyen A, Niman R, Wilson P, Sharma S, Ayers M, Eu P, Stockler MR, Martin AJ, Joshua AM, Emmett L. Quantifying molecular imaging patterns of treatment response or progression using a novel traffic light workflow within a prospective phase I/II trial of 177LuPSMA-617 and NOX66 (LuPIN). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
166 Background: 177Lutetium PSMA-617 (LuPSMA) is an effective therapy for metastatic castrate-resistant prostate cancer (mCRPC). However, treatment resistance may occur. We developed a quantitative workflow for serial PSMA PET/CT to optimise predictive and prognostic imaging biomarker capability for progression free (PFS) and overall survival (OS). Methods: 56 men with mCRPC previously treated with taxane chemotherapy and androgen signaling inhibitor were enrolled, receiving up to 6 doses of LuPSMA and a radiation sensitizer idronoxil (NOX66). 68Ga-PSMA-11 PET/CT was performed at study entry and exit. Traffic Light (TL) quantification workflow was developed to track changes in both tumour volume and intensity at a total body and lesional level. Lesions were classified as responding in green (>30% decline in volume), stable in yellow (<30% change in volume/intensity), progressive in red (>30% increase in volume/intensity, or new). Overall response pattern was categorised as responding ( green/yellow), low volume red (<50% progressive disease) or high volume red (>50% progressive disease). TL workflow results were correlated with PFS and OS. Results: 37/56 men underwent both entry and exit imaging. The median PSA decline was 77% (IQR 34-92%), and 70% (26/37) achieved PSA response >50%. PSA progression occurred in 54% (20/37) at exit imaging. Median PFS was 8.6 months (95%CI 5.6-11.6) and median OS 22 months (95% CI 18.6-25.6). 95% (35/37) had reduction in PSMA SUVmax (-26.1 (IQR +11.7 to -89.4)) and SUVmean (-3.3 (+2.9 to -14.2)). PSMA total tumor volume reduced in 68% (25/37) (median -0.64 liters (range +1.44 to -1.1)). On TL workflow, 24% (9/37) had responding/stable disease ( green/ yellow), 76% (28/37) had progressive disease ( red) of whom 41% (15/37) had low volume progression and 35% (13/37) high volume progression. Men with high volume progression had worse OS compared to responders (HR 0.18 (0.05-0.59), p 0.005), and low volume progression (HR 0.30 (0.11-0.80), p 0.02). 68% (19/28) had progression on both TL workflow and PSA, while 32% (9/28) had progression on TL workflow without PSA progression. In multivariable analysis, TL workflow and PSA progression at time of exit scans were independent predictors of OS (Table). Conclusions: This study demonstrates the feasibility of characterizing lesional response on molecular imaging with a quantification TL workflow. TL workflow response independently correlated with survival outcomes, indicating serial PSMA PET has prognostic biomarker potential. Clinical trial information: ACTRN12618001073291.[Table: see text]
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Affiliation(s)
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia
| | - Andrew O. Yam
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | | | | | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Maria Ayers
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Martin R. Stockler
- NHMRC Clinical Trials Center, University of Sydney, Sydney, NSW, Australia
| | | | - Anthony M. Joshua
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
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Emmett L, Subramaniam S, Martin AJ, Zhang AY, Yip S, Crumbaker M, Rana N, Francis RJ, Hofman MS, Joshua AM, Sandhu SK, Azad A, Gedye C, Weickhardt AJ, Goh JC, Ng S, Voskoboynik M, McJannett MM, Stockler MR, Davis ID. ENZA-p: A randomized phase II trial using PSMA as a therapeutic agent and prognostic indicator in men with metastatic castration-resistant prostate cancer treated with enzalutamide (ANZUP 1901). J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.6_suppl.tps205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS205 Background: 177Lu‐PSMA‐617 (LuPSMA) is a novel radionuclide with promising activity and tolerability in metastatic castration-resistant prostate cancer (mCRPC). Pre-clinical studies have shown that androgen receptor blockade with enzalutamide upregulates PSMA-receptor expression, and that PSMA-receptor blockade increases treatment response to enzalutamide. We hypothesize that concurrent administration of LuPSMA and enzalutamide will be synergistic in mCRPC. The aims of ENZA-p are to determine the activity and safety of LuPSMA combined with enzalutamide in men with mCRPC at high-risk of early progression on enzalutamide alone; and to identify prognostic and predictive biomarkers from imaging, blood, and tissue. Methods: This open-label, randomized, multicentre, phase 2 trial will recruit 160 men with mCRPC. Key eligibility criteria include progression on androgen deprivation therapy, 2 or more risk factors for early cancer progression on enzalutamide (LDH ≥ULN; ALP ≥ULN; albumin < 35 g/L; M1 disease at diagnosis; < 3 years since initial diagnosis; > 5 bone metastases; visceral metastases; PSA doubling time < 3 months; pain requiring opiates > 14 days; for castration-sensitive disease), no prior treatment with an androgen receptor pathway inhibitor (except abiraterone), no prior chemotherapy for mCRPC, and PSMA-avid disease on positron emission tomography (PET) with 68Ga-PSMA. Participants are randomly assigned (1:1) to enzalutamide 160 mg daily or enzalutamide 160 mg daily plus LuPSMA 7.5 GBq on days 15 and 57. Two subsequent doses of Lu-PSMA will be administered if the 68Ga-PSMA PET on day 92 shows persistent PSMA expression in the tumour. Imaging assessments include CT and technetium bone scan at baseline, day 99, then every 12 weeks; 68Ga-PSMA-11 PET at baseline, days 15, 92, and first progression; and 18F FDG PET at baseline and first progression. Translational samples including circulating tumor cells (CTCs), circulating tumor DNA (ctDNA) and biopsies (optional) will be collected at baseline, day 92, and first progression. The primary endpoint is PSA progression-free survival (PSA-PFS). Secondary endpoints include radiological-PFS, PSA-response rate, pain response and PFS, clinical-PFS, overall survival, health related quality of life, adverse events, and cost-effectiveness. Correlative studies include identification of prognostic and predictive biomarkers from 68Ga-PSMA, 18F FDG PET/CT, CTCs, and ctDNA. A sample size of 160 provides 80% power with a 2-sided type 1- error rate of 5% to detect a HR of 0.625 assuming a median PSA-PFS of 5 months with enzalutamide alone. Accrual was 90 on 12 October 2021. Clinical trial information: NCT04419402.
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | | | | | - Alison Yan Zhang
- NHMRC Clinical Trials Center, University of Sydney, Sydney, NSW, Australia
| | - Sonia Yip
- NHMRC Clinical Trials Center, University of Sydney, Camperdown, NSW, Australia
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia
| | - Nisha Rana
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Camperdown, NSW, Australia
| | | | - Michael S Hofman
- Peter MacCallum Cancer Center and University of Melbourne, Melbourne, VIC, Australia
| | - Anthony M. Joshua
- Kinghorn Cancer Center, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | | | - Arun Azad
- Peter MacCallum Cancer Center, Sydney, Australia
| | - Craig Gedye
- Calvary Mater Newcastle, Waratah, NSW, Australia
| | | | - Jeffrey C. Goh
- Royal Brisbane and Women's Hospital, Herston and University of Queensland, St. Lucia, QLD, Australia
| | - Siobhan Ng
- Sir Charles Gairdner Hospital, Perth, Australia
| | | | - Margaret Mary McJannett
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Camperdown, NSW, Australia
| | - Martin R. Stockler
- NHMRC Clinical Trials Center, University of Sydney, Sydney, NSW, Australia
| | - Ian D. Davis
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
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18
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Joshua AM, Gurney H, Dhillon HM, Crumbaker M. Patient Preference or Indifference: Learning from the CABADOC Study. Eur Urol 2021; 81:241-242. [PMID: 34836681 DOI: 10.1016/j.eururo.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Anthony M Joshua
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia; The Garvan Institute for Medical Research, Darlinghurst, Australia; St. Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia
| | - Howard Gurney
- Crown Princess Mary Cancer Centre, Westmead Hospital, Westmead, Australia; Westmead Clinical School, University of Sydney, Westmead, Australia; Macquarie University, Macquarie Park, Australia
| | - Haryana M Dhillon
- The Centre for Medical Psychology & Evidence-based Decision-Making, School of Psychology, Faculty of Science, The University of Sydney, Camperdown, Australia; The Psycho-Oncology Cooperative Research Group, School of Psychology, Faculty of Science, The University of Sydney, Camperdown, Australia
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia; The Garvan Institute for Medical Research, Darlinghurst, Australia; St. Vincent's Clinical School, University of New South Wales, Darlinghurst, Australia.
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19
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Lin HM, Mak B, Yeung N, Huynh K, Meikle TG, Mellett NA, Kwan EM, Fettke H, Tran B, Davis ID, Mahon KL, Zhang A, Stockler MR, Briscoe K, Marx G, Crumbaker M, Stricker PD, Du P, Yu J, Jia S, Scheinberg T, Fitzpatrick M, Bonnitcha P, Sullivan DR, Joshua AM, Azad AA, Butler LM, Meikle PJ, Horvath LG. Overcoming enzalutamide resistance in metastatic prostate cancer by targeting sphingosine kinase. EBioMedicine 2021; 72:103625. [PMID: 34656931 PMCID: PMC8526762 DOI: 10.1016/j.ebiom.2021.103625] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 02/06/2023] Open
Abstract
Background Intrinsic resistance to androgen receptor signalling inhibitors (ARSI) occurs in 20–30% of men with metastatic castration-resistant prostate cancer (mCRPC). Ceramide metabolism may have a role in ARSI resistance. Our study's aim is to investigate the association of the ceramide-sphingosine-1-phosphate (ceramide-S1P) signalling axis with ARSI resistance in mCRPC. Methods Lipidomic analysis (∼700 lipids) was performed on plasma collected from 132 men with mCRPC, before commencing enzalutamide or abiraterone. AR gene aberrations in 77 of these men were identified by deep sequencing of circulating tumour DNA. Associations between circulating lipids, radiological progression-free survival (rPFS) and overall survival (OS) were examined by Cox regression. Inhibition of ceramide-S1P signalling with sphingosine kinase (SPHK) inhibitors (PF-543 and ABC294640) on enzalutamide efficacy was investigated with in vitro assays, and transcriptomic and lipidomic analyses of prostate cancer (PC) cell lines (LNCaP, C42B, 22Rv1). Findings Men with elevated circulating ceramide levels had shorter rPFS (HR=2·3, 95% CI=1·5–3·6, p = 0·0004) and shorter OS (HR=2·3, 95% CI=1·4–36, p = 0·0005). The combined presence of an AR aberration with elevated ceramide levels conferred a worse prognosis than the presence of only one or none of these characteristics (median rPFS time = 3·9 vs 8·3 vs 17·7 months; median OS time = 8·9 vs 19·8 vs 34·4 months). SPHK inhibitors enhanced enzalutamide efficacy in PC cell lines. Transcriptomic and lipidomic analyses indicated that enzalutamide combined with SPHK inhibition enhanced PC cell death by SREBP-induced lipotoxicity. Interpretation Ceramide-S1P signalling promotes ARSI resistance, which can be reversed with SPHK inhibitors.
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Affiliation(s)
- Hui-Ming Lin
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia
| | - Blossom Mak
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | - Nicole Yeung
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia
| | - Kevin Huynh
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Thomas G Meikle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Edmond M Kwan
- Department of Medical Oncology, Monash Health, Clayton, Victoria, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Heidi Fettke
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Ben Tran
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Ian D Davis
- Cancer Services, Eastern Health, Box Hill, Victoria, Australia; Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
| | - Kate L Mahon
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia; Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Alison Zhang
- Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Martin R Stockler
- Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Concord Repatriation General Hospital, Concord, New South Wales, Australia
| | - Karen Briscoe
- Mid North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Gavin Marx
- Sydney Adventist Hospital, Wahroonga, New South Wales, Australia
| | - Megan Crumbaker
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia; The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Phillip D Stricker
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia
| | - Pan Du
- Predicine, Inc., Hayward, CA, USA
| | | | | | - Tahlia Scheinberg
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia
| | | | - Paul Bonnitcha
- University of Sydney, Camperdown, New South Wales, Australia; NSW Health Pathology, Camperdown, New South Wales, Australia
| | - David R Sullivan
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; NSW Health Pathology, Camperdown, New South Wales, Australia
| | - Anthony M Joshua
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia; The Kinghorn Cancer Centre, St Vincent's Hospital, Darlinghurst, New South Wales, Australia
| | - Arun A Azad
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Victoria, Australia
| | - Lisa M Butler
- Adelaide Medical School and Freemason's Centre for Male Health and Wellbeing, University of Adelaide, Adelaide, South Australia, Australia; South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Peter J Meikle
- Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Lisa G Horvath
- Garvan Institute of Medical Research, Darlinghurst, Sydney, New South Wales, Australia; St Vincent's Clinical School, UNSW Sydney, Darlinghurst, New South Wales, Australia; Chris O' Brien Lifehouse, Camperdown, New South Wales, Australia; University of Sydney, Camperdown, New South Wales, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.
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20
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Sandhu S, Joshua A, Emmett L, Spain L, Horvath L, Crumbaker M, Anton A, Wallace R, Pasam A, Bressel M, Cassidy E, Banks P, Kumar A, Alipour R, Akhurst T, Kong G, Davis I, Williams S, Hicks R, Hofman M. 577O PRINCE: Interim analysis of the phase Ib study of 177Lu-PSMA-617 in combination with pembrolizumab for metastatic castration resistant prostate cancer (mCRPC). Ann Oncol 2021. [DOI: 10.1016/j.annonc.2021.08.1090] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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21
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Pathmanandavel S, Crumbaker M, Yam AO, Nguyen A, Rofe C, Hovey E, Gedye C, Kwan EM, Hauser C, Azad AA, Eu P, Martin AJ, Joshua AM, Emmett L. 177Lutetium PSMA-617 and idronoxil (NOX66) in men with end-stage metastatic castrate-resistant prostate cancer (LuPIN): Patient outcomes and predictors of treatment response of a Phase I/II trial. J Nucl Med 2021; 63:560-566. [PMID: 34326127 PMCID: PMC8973290 DOI: 10.2967/jnumed.121.262552] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 06/29/2021] [Indexed: 11/29/2022] Open
Abstract
177Lu-PSMA-617 is an effective therapy for metastatic castration-resistant prostate cancer (mCRPC). However, treatment resistance occurs frequently, and combination therapies may improve outcomes. We report the final safety and efficacy results of a phase I/II study combining 177Lu-PSMA-617 with idronoxil (NOX66), a radiosensitizer, and examine potential clinical, blood-based, and imaging biomarkers. Methods: Fifty-six men with progressive mCRPC previously treated with taxane chemotherapy and novel androgen signaling inhibitor (ASI) were enrolled. Patients received up to 6 doses of 177Lu-PSMA-617 (7.5 GBq) on day 1 in combination with a NOX66 suppository on days 1–10 of each 6-wk cycle. Cohort 1 (n = 8) received 400 mg of NOX66, cohort 2 (n = 24) received 800 mg, and cohort 3 (n = 24) received 1,200 mg. 68Ga-PSMA and 18F-FDG PET/CT were performed at study entry, and semiquantitative imaging analysis was undertaken. Blood samples were collected for analysis of blood-based biomarkers, including androgen receptor splice variant 7 expression. The primary outcomes were safety and tolerability; secondary outcomes included efficacy, pain scores, and xerostomia. Regression analyses were performed to explore the prognostic value of baseline clinical, blood-based, and imaging parameters. Results: Fifty-six of the 100 men screened were enrolled (56%), with a screening failure rate of 26% (26/100) for PET imaging criteria. All men had received prior treatment with ASI and docetaxel, and 95% (53/56) had received cabazitaxel. Ninety-six percent (54/56) of patients received at least 2 cycles of combination NOX66 and 177Lu-PSMA-617, and 46% (26/56) completed 6 cycles. Common adverse events were anemia, fatigue, and xerostomia. Anal irritation attributable to NOX66 occurred in 38%. Forty-eight of 56 had a reduction in prostate-specific antigen (PSA) level (86%; 95% CI, 74%–94%); 34 of 56 (61%; 95% CI, 47%–74%) had a PSA reduction of at least 50%. Median PSA progression-free survival was 7.5 mo (95% CI, 5.9–9 mo), and median overall survival was 19.7 mo (95% CI, 9.5–30 mo). A higher PSMA SUVmean correlated with treatment response, whereas a higher PSMA tumor volume and prior treatment with ASI for less than 12 mo were associated with worse overall survival. Conclusion: NOX66 with 177Lu-PSMA-617 is a safe and feasible strategy in men being treated with third-line therapy and beyond for mCRPC. PSMA SUVmean, PSMA-avid tumor volume, and duration of treatment with ASI were independently associated with outcome.
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Affiliation(s)
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St Vincent's Hospital, Australia
| | - Andrew O Yam
- The Kinghorn Cancer Centre, St Vincent's Hospital, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital Sydney, Australia, Australia
| | | | - Elizabeth Hovey
- Nelune Comprehensive Cancer Centre, Prince of Wales Hospital, Australia
| | - Craig Gedye
- Department of Medical Oncology, Calvary Mater Hospital, Australia
| | - Edmond M Kwan
- Department of Medicine, School of Clinical Sciences, Monash University, Australia
| | | | | | - Peter Eu
- Peter MacCallum Cancer Centre, Australia
| | - Andrew J Martin
- NHMRC Clinical Trials Centre, University of Sydney, Australia
| | | | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Australia
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22
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Arasaratnam M, Balakrishnar B, Crumbaker M, Turner S, Hayden AJ, Brooks A, Patel MI, Lau H, Woo H, Bariol S, Gurney H. Patterns of care and outcomes of men with germ cell tumors in a high-volume Australian center. Asia Pac J Clin Oncol 2021; 18:e23-e31. [PMID: 34152083 DOI: 10.1111/ajco.13548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 11/30/2020] [Indexed: 11/27/2022]
Abstract
AIM To evaluate disease presentation, treatment practices, and outcomes of patients with germ cell tumor (GCT) treated in a high-volume cancer center in Australia. METHODS This is a retrospective analysis of 609 patients diagnosed with GCT in the Sydney West Cancer Network between 1990 and 2013. Cause and date of death, and second malignancy information was sourced from The Centre for Health Record Linkage. RESULTS The median age was 33 years (range, 14-85). Primary site was testis in 590 (96.9%), mediastinum in nine (1.5%), and retroperitoneum in nine (1.5%). History of undescended testis was present in 48 (7.9%). Pure seminoma was seen in 334 (54.8%), with 274 (82.0%) being stage I. There was a decline in use of adjuvant radiotherapy from 83% in 1990-1997 to 29% in 2006-2013. Nonseminoma GCT (NSGCT) was diagnosed in 275 (45.2%), with 162 (58.9%) being stage 1. Active surveillance has increased as the initial treatment, from 58% between 1990 and 1997 to 89% between 2006 and 2013. Metastatic disease at presentation was seen in 162 (26.6%): 55 (34.0%) seminoma and 107 (66.0%) NSGCT. With median of 15-year follow-up, 18 (3.0%) have died from GCT and 70 (11.5%) from all causes. Ten-year overall survival was 93% and GCT-specific survival was 97%. Forty patients developed a secondary malignancy, with 38 receiving chemotherapy, radiotherapy, or both. CONCLUSIONS This large Australian series illustrates a changing pattern of care and outcomes and compares them favorably with other series. This serves as a basis for future comparison of outcomes for this malignancy.
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Affiliation(s)
- Malmaruha Arasaratnam
- Department of Medical Oncology, Gosford Hospital, Sydney, New South Wales, Australia
| | - Bavanthi Balakrishnar
- Department of Medical Oncology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Megan Crumbaker
- Department of Medical Oncology, The Kinghorn Cancer Centre, Sydney, New South Wales, Australia
| | - Sandra Turner
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Amy J Hayden
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Andrew Brooks
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, Sydney, New South Wales, Australia
| | - Manish I Patel
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, Sydney, New South Wales, Australia
| | - Howard Lau
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Henry Woo
- Discipline of Surgery, Sydney Medical School, Sydney, New South Wales, Australia.,Chris O'Brien Lifehouse, Camperdown, New South Wales, Australia
| | - Simon Bariol
- Department of Urology, Westmead Hospital, Sydney, New South Wales, Australia.,Discipline of Surgery, Sydney Medical School, Sydney, New South Wales, Australia
| | - Howard Gurney
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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23
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Emmett L, Subramaniam S, Joshua AM, Crumbaker M, Martin A, Zhang AY, Rana N, Langford A, Mitchell J, Yip S, Francis R, Hofman MS, Sandhu S, Azad A, Gedye C, McJannett M, Stockler MR, Davis ID. ENZA-p trial protocol: a randomized phase II trial using prostate-specific membrane antigen as a therapeutic target and prognostic indicator in men with metastatic castration-resistant prostate cancer treated with enzalutamide (ANZUP 1901). BJU Int 2021; 128:642-651. [PMID: 34028967 DOI: 10.1111/bju.15491] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the activity and safety of lutetium-177 (177 Lu)-prostate-specific membrane antigen (PSMA)-617 in men with metastatic castration-resistant prostate cancer (mCRPC) commencing enzalutamide, who are at high risk of early progression, and to identify potential prognostic and predictive biomarkers from imaging, blood and tissue. PARTICIPANTS AND METHODS ENZA-p (ANZUP 1901) is an open-label, randomized, two-arm, multicentre, phase 2 trial. Participants are randomly assigned (1:1) to treatment with enzalutamide 160 mg daily alone or enzalutamide plus 177 Lu-PSMA-617 7.5 GBq on Days 15 and 57. Two additional 177 Lu-PSMA-617 doses are allowed, informed by Day-92 Gallium-68 (68 Ga)-PSMA positron emission tomography (PET; up to four doses in total). The primary endpoint is prostate-specific antigen (PSA) progression-free survival (PFS). Other major endpoints include radiological PFS, PSA response rate, overall survival, health-related quality of life, adverse events and cost-effectiveness. Key eligibility criteria include: biochemical and/or clinical progression; 68 Ga-PSMA PET-avid disease; no prior androgen signalling inhibitor, excepting abiraterone; no prior chemotherapy for mCRPC; and ≥2 high-risk features for early enzalutamide failure. Assessments are 4 weekly during study treatment, then 6 weekly until radiographic progression. Response Evaluation Criteria in Solid Tumours (RECIST) are used to assess imaging conducted every 12 weeks, 68 Ga-PSMA PET at baseline, Days 15 and 92, and at progression, and 18 F-fluorine deoxyglucose (18 F-FDG) PET at baseline and progression. Translational samples include blood (and optional biopsies) at baseline, Day 92, and first progression. Correlative studies include identification of prognostic and predictive biomarkers from 68 Ga-PSMA and 18 F-FDG PET/CT, circulating tumour cells and circulating tumour DNA. The trial will enrol 160 participants, providing 80% power with a two-sided type-1 error rate of 5% to detect a hazard ratio of 0.625 assuming a median PSA-PFS of 5 months with enzalutamide alone. RESULTS AND CONCLUSION The combination of 177 Lu-PSMA-617 and enzalutamide may be synergistic. ENZA-p will determine the safety and efficacy of the combination in addition to developing predictive and prognostic biomarkers to better guide treatment decisions.
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,Garvan Institute of Medical Research, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia
| | | | - Anthony M Joshua
- Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Megan Crumbaker
- Garvan Institute of Medical Research, Sydney, NSW, Australia.,University of New South Wales, Sydney, NSW, Australia.,Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew Martin
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Alison Y Zhang
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Nisha Rana
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Sydney, NSW, Australia
| | - Ailsa Langford
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Jenna Mitchell
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Sonia Yip
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia
| | - Shahneen Sandhu
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia
| | - Arun Azad
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia
| | - Craig Gedye
- Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Margaret McJannett
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Sydney, NSW, Australia
| | - Martin R Stockler
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Ian D Davis
- Eastern Health Clinical School, Monash University, Melbourne, Vic., Australia.,Eastern Health, Melbourne, Vic., Australia
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24
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Chan DL, Pavlakis N, Crumbaker M, Lawrence B, Barber C, Price TJ, Michael M, Oberg K. Vigilance for carcinoid heart disease is still required in the era of somatostatin analogues: Lessons from a case series. Asia Pac J Clin Oncol 2021; 18:209-216. [PMID: 33852771 DOI: 10.1111/ajco.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
AIM Carcinoid heart disease (CHD) is a well-documented complication of neuroendocrine tumors (NETs) due to secreted hormones causing fibrosis. Somatostatin analogues (SSAs) can decrease hormonal secretion and inhibit tumor growth. The reported incidence of CHD has decreased as SSA use has increased. We describe a series of patients who have developed CHD even though they were treated with SSA therapy. METHODS Nine patients were seen in four centers in Australia and New Zealand. The average duration of follow-up from diagnosis was 39 months. RESULTS Three patients had Grade 1 and six Grade 2 disease by World Health Organization 2010 criteria. All patients had no CHD symptoms at baseline and started SSA therapy soon after diagnosis, yet developed significant, symptomatic cardiac dysfunction in their disease course. The median time from NET diagnosis to SSA initiation was 1 month, and median time from NET diagnosis to CHD diagnosis was 23 months (range 4-52). All patients who were tested had persistently increased hormonal levels (chromogranin A, urinary 5-hydroxyindolacetic acid). CONCLUSIONS The good symptomatic control afforded by SSAs should not lead to reduced vigilance in screening for CHD, especially in patients with persistently elevated hormonal assays. Clinicians should consider regular echocardiographic screening in patients with a secretory syndrome.
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Affiliation(s)
- David L Chan
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Megan Crumbaker
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ben Lawrence
- Discipline of Oncology, University of Auckland, Auckland, New Zealand
| | - Camilla Barber
- The School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Michael Michael
- Division of Cancer Medicine & Neuroendocrine Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Kjell Oberg
- Department of Endocrine Oncology, University Hospital, Uppsala, Sweden
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25
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Kwan EM, Fettke H, Crumbaker M, Docanto MM, To SQ, Bukczynska P, Mant A, Ng N, Foroughi S, Graham LJK, Haynes AM, Azer S, Lim LE, Segelov E, Mahon K, Davis ID, Parente P, Pezaro C, Todenhöfer T, Sathianathen N, Hauser C, Horvath LG, Joshua AM, Azad AA. Whole blood GRHL2 expression as a prognostic biomarker in metastatic hormone-sensitive and castration-resistant prostate cancer. Transl Androl Urol 2021; 10:1688-1699. [PMID: 33968657 PMCID: PMC8100842 DOI: 10.21037/tau-20-1444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background As potent systemic therapies transition earlier in the prostate cancer disease course, molecular biomarkers are needed to guide optimal treatment selection for metastatic hormone-sensitive prostate cancer (mHSPC). The value of whole blood RNA to detect candidate biomarkers in mHSPC remains largely undefined. Methods In this cohort study, we used a previously optimised whole blood reverse transcription polymerase chain reaction assay to assess the prognostic utility [measured by seven-month undetectable prostate-specific antigen (PSA) and time to castration-resistance (TTCR)] of eight prostate cancer-associated gene transcripts in 43 mHSPC patients. Transcripts with statistically significant associations (P<0.05) were further investigated in a metastatic castration-resistant prostate cancer (mCRPC) cohort (n=119) receiving contemporary systemic therapy, exploring associations with PSA >50% response (PSA50), progression-free survival (PFS) and overall survival (OS). Clinical outcomes were prospectively collected in a protected digital database. Kaplan-Meier estimates and multivariable Cox proportional-hazards models assessed associations between gene transcripts and clinical outcomes (mHSPC covariates: disease volume, docetaxel use and haemoglobin level; mCRPC covariates: prior exposure to chemotherapy or ARPIs, haemoglobin, performance status and presence of visceral disease). Follow-up was performed monthly during ARPI treatment, three-weekly during taxane chemotherapy, and three-monthly during androgen deprivation therapy (ADT) monotherapy. Serial PSA measurements were performed before each follow-up visit and repeat imaging was at the discretion of the investigator. Results Detection of circulating Grainyhead-like 2 (GRHL2) transcript was associated with poor outcomes in mHSPC and mCRPC patients. Detectable GRHL2 expression in mHSPC was associated with a lower rate of seven-month undetectable PSA levels (25% vs. 65%, P=0.059), and independently associated with shorter TTCR (HR 7.3, 95% CI: 1.5–36, P=0.01). In the mCRPC cohort, GRHL2 expression predicted significantly lower PSA50 response rates (46% vs. 69%, P=0.01), and was independently associated with shorter PFS (HR 3.1, 95% CI: 1.8–5.2, P<0.001) and OS (HR 2.9, 95% CI: 1.6–5.1, P<0.001). Associations were most apparent in patients receiving ARPIs. Conclusions Detectable circulating GRHL2 was a negative prognostic biomarker in our mHSPC and mCRPC cohorts. These data support further investigation of GRHL2 as a candidate prognostic biomarker in metastatic prostate cancer, in addition to expanding efforts to better understand a putative role in therapeutic resistance to AR targeted therapies.
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Affiliation(s)
- Edmond M Kwan
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Medical Oncology, Monash Health, Melbourne, Australia
| | - Heidi Fettke
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Megan Crumbaker
- Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, New South Wales, Australia.,Garvan Institute of Medical Research, New South Wales, Australia.,University of Sydney, New South Wales, Australia
| | - Maria M Docanto
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Sarah Q To
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia
| | | | - Andrew Mant
- Department of Medical Oncology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Nicole Ng
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Siavash Foroughi
- Personalised Oncology Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Department of Medical Biology, The University of Melbourne, Melbourne, Australia
| | | | | | - Sarah Azer
- Department of Urology, Monash Health, Melbourne, Australia
| | | | - Eva Segelov
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Medical Oncology, Monash Health, Melbourne, Australia
| | - Kate Mahon
- Garvan Institute of Medical Research, New South Wales, Australia.,University of Sydney, New South Wales, Australia.,Medical Oncology, Chris O'Brien Lifehouse, New South Wales, Australia
| | - Ian D Davis
- Department of Medical Oncology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Phillip Parente
- Department of Medical Oncology, Eastern Health, Melbourne, Australia.,Eastern Health Clinical School, Monash University, Melbourne, Australia
| | | | | | - Niranjan Sathianathen
- Division of Cancer Surgery, Peter MacCallum Cancer Centre, University of Melbourne, Melbourne, Australia
| | | | - Lisa G Horvath
- Garvan Institute of Medical Research, New South Wales, Australia.,University of Sydney, New South Wales, Australia.,Medical Oncology, Chris O'Brien Lifehouse, New South Wales, Australia.,Royal Prince Alfred Hospital, New South Wales, Australia
| | - Anthony M Joshua
- Department of Medical Oncology, Kinghorn Cancer Centre, St Vincent's Hospital, New South Wales, Australia.,Garvan Institute of Medical Research, New South Wales, Australia
| | - Arun A Azad
- Department of Medicine, School of Clinical Sciences, Monash University, Melbourne, Australia.,Department of Medical Oncology, Peter MacCallum Cancer Centre, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Australia
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26
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Pathmanandavel S, Crumbaker M, Yam AOW, Rofe C, Ho B, Chan WL, Sharma S, Hickey AJ, Kongrak K, Ratnayake L, Kwan EM, Azad A, Eu P, Nguyen A, Joshua AM, Emmett L. Final results of a phase I/II prospective dose escalation trial evaluating safety and efficacy of combination 177Lu PSMA 617 and NOX66 in men with end-stage metastatic castration-resistant prostate cancer (LuPIN trial). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
103 Background: 177LuPSMA – 617 is a promising therapy for metastatic castrate-resistant prostate cancer (mCRPC). However, treatment resistance occurs frequently and synergistic combination therapy may improve outcomes. We combined 177LuPSMA – 617 with idronoxil (NOX66), an inhibitor of external NADH oxidase type 2 with radio-sensitizing properties. We present the final safety and efficacy results. Methods: Men with progressive mCRPC after androgen signalling inhibition (ASI) and taxane chemotherapy were enrolled. Key inclusion criteria were: PSMA PET/CT intensity SUV max > 15 with no discordant disease on FDG PET/CT, haemoglobin > 100g/L, platelets > 100x109/L and eGFR > 40mls/min. Enrolled patients received up to six doses of 177 Lu-PSMA 617 (7.5Gbq) day 1 every 6 weeks in combination with NOX66 days 1-10 each cycle. Cohort 1 (n = 8) received 400mg NOX66. Following safety reviews the doses were escalated in cohorts 2 (n = 24) and 3 (n = 24) to 800mg and 1200mg of NOX66, respectively. Blood samples were prospectively collected for androgen receptor splice variant 7 (ARV7) expression. PSMA and FDG PET/CT were performed at study entry and on progression. The primary outcomes were safety and tolerability; the secondary outcomes evaluated were efficacy, pain scores, and quality of life. Results: Of the 56 men enrolled, all had received prior treatment with ASI and docetaxel, and 95% (53/56) had prior cabazitaxel. 96% (54/56) patients received ≥2 cycles and 46% (26/56) completed six cycles of treatment. Adverse events are summarized in the table below. PSA responses were as follows: 86% (48/56) had any PSA reduction and 61% (34/56) had > 50% PSA reduction. 84% (47/56) have had PSA progression to date with median follow up 18.9 months (95% CI 11.9-25.8). Median PSA PFS was 7.5 months (95% CI 6.0-9.0). 55% (31/56) have died and median overall survival was 19.7 months (95% CI 10.7-28.7). 34/56 men had baseline pain scores ≥3, of whom 53% (18/34) had significant reduction in pain indicators. There was no correlation between quantitative PET results and either PSA > 50% response, PSA PFS or OS. Conclusions: The combination of 177 Lu-PSMA 617 + NOX66 appears safe and efficacious in men with heavily pre-treated mCRPC. Exploratory analysis of ARV7 expression and quantitative PET imaging markers of treatment response and resistance is in progress. Clinical trial information: ACTRN12618001073291. [Table: see text]
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Affiliation(s)
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew On Wah Yam
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Christopher Rofe
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Bao Ho
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Wai Ling Chan
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Adam James Hickey
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Kamonwan Kongrak
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Lalith Ratnayake
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | | | - Arun Azad
- Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Anthony M. Joshua
- Kinghorn Cancer Center, St. Vincent’s Hospital, Sydney, NSW, Australia
| | - Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, NSW, Australia
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27
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Emmett L, Subramaniam S, Zhang AY, Martin AJ, Yip S, Crumbaker M, Rana N, Ford K, Langford A, Francis RJ, Hofman MS, Joshua AM, Sandhu SK, Azad A, Gedye C, McJannett MM, Stockler MR, Davis ID. ENZA-p: A randomized phase II trial using PSMA as a therapeutic agent and prognostic indicator in men with metastatic castration-resistant prostate cancer treated with enzalutamide (ANZUP 1901). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.tps177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS177 Background: 177Lu‐PSMA‐617 (LuPSMA) is a novel radionuclide with promising activity and tolerability in metastatic, castration-resistant prostate cancer (mCRPC). Pre-clinical studies have shown that androgen receptor blockade with enzalutamide upregulates PSMA-receptor expression, and that PSMA-receptor blockade increases treatment response to enzalutamide. We hypothesise that concurrent administration of LuPSMA and enzalutamide will be synergistic in mCRPC. The aims of ENZA-p are to determine the activity and safety of LuPSMA and enzalutamide in men with mCRPC at high-risk of early progression on enzalutamide alone; and to identify potential prognostic and predictive biomarkers from imaging, blood, and tissue. Methods: This open-label, randomised, multicentre, phase 2 trial will recruit 160 men with mCRPC. Key eligibility criteria include progression on androgen deprivation therapy, 2 or more high-risk features for early (LDH ≥ULN; ALP ≥ULN; albumin <35 g/L; M1 disease at diagnosis; <3 years from initial diagnosis to randomisation; >5 bone metastases; visceral metastases; PSA doubling time <84 days; pain requiring opiates >14 days; prior abiraterone), no prior treatment with a novel androgen signalling inhibitor (except abiraterone), no prior chemotherapy for mCRPC, and PSMA-avid disease on positron emission tomography (PET) with 68Ga-PSMA. Participants are randomly assigned (1:1) enzalutamide 160 mg daily or enzalutamide 160 mg daily plus LuPSMA 7.5 GBq on days 15 and 57. Two subsequent doses of Lu-PSMA will be administered if the 68Ga-PSMA PET on day 92 shows persistent PSMA expression in the tumour. Imaging assessments include CT and technetium bone scan at baseline, day 99, then every 12 weeks; 68Ga-PSMA-11 PET at baseline, days 15, 92, and first progression; and 18F FDG PET at baseline and first progression. Translational samples including circulating tumour cells (CTCs), circulating tumour DNA (ctDNA) and biopsies (optional) will be collected at baseline, day 92, and first progression. The primary endpoint is PSA progression-free survival (PSA-PFS). Secondary endpoints include radiological-PFS, PSA-response rate, pain response and PFS, clinical-PFS, overall survival, health related quality of life, adverse events, and cost-effectiveness. Correlative studies include identification of prognostic and predictive biomarkers from 68Ga-PSMA, 18F FDG PET/CT, CTCs, and ctDNA. A sample size of 160 provides 80% power with a 2-sided type 1-error rate of 5% to detect a HR of 0.625 assuming a median PSA-PFS of 5 months with enzalutamide alone. Accrual was 5 on 13 October 2020. ENZA-p is an investigator-initiated, academic trial led by ANZUP in collaboration with the NHMRC Clinical Trials Centre, University of Sydney. Clinical trial information: NCT04419402.
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, NSW, Australia
| | | | - Alison Yan Zhang
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | - Sonia Yip
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Nisha Rana
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Camperdown, NSW, Australia
| | - Kate Ford
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Ailsa Langford
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | | | | | | | | | - Arun Azad
- Peter MacCallum Cancer Center, Melbourne, VIC, Australia
| | - Craig Gedye
- Calvary Mater Newcastle, Waratah, NSW, Australia
| | - Margaret Mary McJannett
- Australian and New Zealand Urogenital and Prostate Cancer Trials Group, Camperdown, NSW, Australia
| | - Martin R. Stockler
- NHMRC Clinical Trials Center, University of Sydney, Sydney, NSW, Australia
| | - Ian D. Davis
- Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
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28
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Lau B, Crumbaker M, Yam AOW, Marastoni S, Luckhurst M, O'Grady A, Wouters B, Joshua AM. A phase I/II study of hydroxychloroquine and suba-itraconazole in men with biochemical relapse of prostate cancer (HITMAN-PC): Dose escalation results. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.6_suppl.114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
114 Background: Preclinical data show hydroxychloroquine (HCQ) and suba-itraconazole (SI) together enhance prostate cancer cell death. The proposed mechanism is lysosome dysfunction including sequestration of cholesterol in endosomes and inhibition of gogi-lyosome trafficking. HCQ/SI could delay androgen deprivation therapy (ADT) and its associated morbidity in men with biochemical relapse of prostate cancer. In this phase I/II study, maximum tolerated dose (MTD), recommended phase II dose (RP2D), safety, pharmacokinetics (PK), and preliminary activity of HCQ/SI was investigated in such patients. Methods: Patients received escalating doses of HCQ with fixed SI 150mg BD in rolling 6 design. This will be followed by a planned phase II Simon 2-stage cohort expansion. Results: Eleven men were treated with HCQ/SI. Median age 73 (range 69-77), baseline PSA 4.4 µg/L (1.6-22.4) and doubling time 5.3 months (3.3-15.3). Two experienced dose-limiting toxicity: grade 3 diarrhoea and grade 3 alanine transferase elevation, both at HCQ 600mg BD. Most common treatment-related adverse events (AEs) were hypertension (91% all grade/18% grade 3), QTc prolongation (55%/0%), diarrhoea (36%/9%), and nausea (36%/0%). There were no grade 4 AEs or deaths. While there were no PSA responses (≥50% fall from baseline), PSA PFS by PCWG3 criteria was 5.5 months (2.0-9.0), and PSA doubling time was prolonged at 4 and 12 weeks in 82% and 45% respectively. ADT-free and metastasis-free survival are 14.3 months (95% CI 4.9-23.8) and 15.9 months (95% CI unevaluable) respectively. PK data will be presented. Conclusions: HCQ/SI demonstrated acceptable safety with MTD 600mg BD and RP2D 400mg BD. There is early signal of activity and phase II enrolment is to begin. Clinical trial information: NCT03513211.
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Affiliation(s)
- Brandon Lau
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Megan Crumbaker
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Andrew On Wah Yam
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stefano Marastoni
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Mathew Luckhurst
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Aaron O'Grady
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
| | - Brad Wouters
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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29
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Bhatnagar A, McKay MJ, Arasaratnam M, Crumbaker M, Gurney H, Molloy MP. Evaluating bioanalytical capabilities of paper spray ionization for abiraterone drug quantification in patient plasma. J Mass Spectrom 2020; 55:e4584. [PMID: 32725840 DOI: 10.1002/jms.4584] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 05/17/2020] [Accepted: 05/27/2020] [Indexed: 06/11/2023]
Abstract
Paper spray ionization (PSI) is a direct, fast, and low-cost ambient ionization technique which may have clinical utility for qualitative and quantitative analysis of therapeutic drugs and metabolites from patient specimens. We developed and validated a PSI-mass spectrometry (PSI-MS/MS) method according to the US-FDA guidelines for bioanalytical studies to measure the prostate cancer drug abiraterone directly from patient plasma. The established linearity range was 3.1-156.8 ng/mL with a precision (%CV) and an accuracy (%) range of 0.5-10.7 and 93.5-103.2, respectively. The mean internal standard normalized matrix factor for abiraterone was just below 1 with highest %CV of 10.2 at the low-level quality control. In benchmarking the performance of this assay against a published LC-MS/MS assay, we showed they were mostly equivalent, with the exception of accuracy with clinical samples. We found the quantitative values observed for abiraterone measured directly from patient plasma using PSI-MS/MS showed positive bias. Upon investigation, we concluded the increased values were due to summed quantitation of isomeric abiraterone conjugates and metabolites which are separable by LC-MS/MS, but not with the current PSI-MS/MS configuration. Despite demonstrating the utility of PSI-MS/MS for rapid bioanalysis, this study also highlighted a limitation encountered with the direct analysis of abiraterone in clinical samples.
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Affiliation(s)
- Atul Bhatnagar
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
- Australian Proteome Analysis Facility, Macquarie University, Sydney, Australia
| | - Matthew J McKay
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
- Australian Proteome Analysis Facility, Macquarie University, Sydney, Australia
| | | | - Megan Crumbaker
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Howard Gurney
- Department of Clinical Sciences, Macquarie University, Sydney, Australia
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
| | - Mark P Molloy
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
- Australian Proteome Analysis Facility, Macquarie University, Sydney, Australia
- Bowel Cancer and Biomarker Laboratory, Kolling Institute, The University of Sydney, Sydney, Australia
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30
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Crumbaker M, Pathmanandavel S, Yam AO, Nguyen A, Ho B, Chan L, Ende JA, Rofe C, Kongrak K, Kwan EM, Azad AA, Sharma S, Pugh TJ, Danesh A, Keane J, Eu P, Joshua AM, Emmett L. Phase I/II Trial of the Combination of 177Lutetium Prostate specific Membrane Antigen 617 and Idronoxil (NOX66) in Men with End-stage Metastatic Castration-resistant Prostate Cancer (LuPIN). Eur Urol Oncol 2020; 4:963-970. [PMID: 32758400 DOI: 10.1016/j.euo.2020.07.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/26/2020] [Accepted: 07/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Trials of lutetium prostate specific membrane antigen (PSMA) in men with metastatic castration-resistant prostate cancer (mCRPC) have demonstrated good safety and efficacy, but combination strategies may improve outcomes. Idronoxil is a synthetic flavonoid derivative with radiosensitising properties. OBJECTIVE To evaluate the safety and activity of 177Lu PSMA 617 (LuPSMA-617) in combination with idronoxil suppositories (NOX66) in patients with end-stage mCRPC. DESIGN, SETTING, AND PARTICIPANTS Thirty-two men with progressive mCRPC previously treated with taxane-based chemotherapy (91% treated with both docetaxel and cabazitaxel) and abiraterone and/or enzalutamide were enrolled in this phase I dose escalation study with phase II dose expansion. INTERVENTION Screening with 68Ga PSMA and 18F-fludeoxyglucose positron emission tomography (PET)/computed tomography (CT) was performed. Men received up to six cycles of LuPSMA-617 (7.5 GBq) on day 1, with escalating doses of NOX66 on days 1-10 of a 6-wk cycle. Cohort 1 (n = 8) received 400 mg and cohort 2 (n = 24) 800 mg of NOX66. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Adverse events (AEs), pain inventory scores, prostate-specific antigen (PSA) response, progression-free survival, and overall survival were evaluated. RESULTS AND LIMITATIONS Fifty-six men were screened and 32 (57%) were enrolled with a screen failure rate of 21% for PET imaging criteria. Dosing was as follows: 97% (31/32) received two or more doses and 47% (15/32) completed six doses. Common AEs included xerostomia, fatigue, and anaemia. Anal irritation attributable to NOX66 occurred in 28%. PSA responses were as follows: 91% (29/32) had any PSA response (median -74%; 95% confidence interval [CI] 76-97) and 62.5% (20/32) had a PSA fall of >50% (95% CI 45-77). The median PSA progression-free survival was 6.1 mo (95% CI 2.8-9.2) and median overall survival was 17.1 mo (95% CI 6.5-27.1). CONCLUSIONS NOX66 with LuPSMA-617 is a safe and feasible therapeutic strategy in men treated with third-line therapy and beyond for mCRPC. PATIENT SUMMARY Addition of NOX66 to 177Lu prostate-specific membrane antigen 617 is safe, and further studies are needed to assess its potential to augment the anticancer effects of LuPSMA-617.
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Affiliation(s)
- Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia; St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia; Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | | | - Andrew O Yam
- The Kinghorn Cancer Centre, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia; St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia; Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Bao Ho
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Lyn Chan
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Jesse A Ende
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Christopher Rofe
- The Kinghorn Cancer Centre, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Kamonwan Kongrak
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Edmond M Kwan
- Department of Medical Oncology, Monash Health, Clayton, VIC, Australia; Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Arun A Azad
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Peter MacCallum Cancer Centre, Parkville, VIC, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Trevor J Pugh
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Arnavaz Danesh
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Joanne Keane
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Peter Eu
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Anthony M Joshua
- The Kinghorn Cancer Centre, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia; St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia; Garvan Institute of Medical Research, Darlinghurst, NSW, Australia
| | - Louise Emmett
- St. Vincent's Clinical School, University of New South Wales, Kensington, NSW, Australia; Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital Sydney, Darlinghurst, NSW, Australia.
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Emmett L, Pathmanandavel S, Crumbaker M, Rofe C, Yam AOW, Ho B, Chan WL, Sharma S, Keane J, Hickey AJ, Fullard K, Kongrak K, Ratnayake L, Violet JA, Azad A, Eu P, Nguyen A, Joshua AM. Updated results of a phase I/II prospective dose escalation trial evaluating safety and efficacy of combination 177Lu PSMA 617 and idronoxil in men with mCRPC post androgen signalling inhibition and taxane chemotherapy (LuPIN trial). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.5557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
5557 Background: There is no established standard of care post cabazitaxel in men with mCRPC. Ongoing trials in 177LuPSMA-617 have demonstrated good efficacy and safety, but synergistic combinations may further improve treatment responses. Idronoxil (NOX66) inhibits external NADH oxidase type 2 with downstream pro-apoptotic actions including radio-sensitization. Herein we present updated results and an additional cohort of a prospective single arm phase I/II dose escalation/expansion trial of LuPSMA-617 and NOX66 in mCRPC. Methods: Men with progressive mCRPC post androgen signalling inhibition (ASI) and 2 lines of taxane chemotherapy were considered eligible. Key inclusion criteria included PSMA PET/CT intensity SUV max > 15 with no discordant disease on FDG PET/CT, Hb >10, Platelets >100 and GFR >40mls/min. Enrolled patients received up to 6 doses of 177 Lu-PSMA 617 (7.5Gbq) day 1 every 6 weeks in combination with NOX66 days 1-10 each cycle. Cohort 1 (n=8) received 400mg NOX66. Cohorts 2 and 3 subsequently received 800mg and 1200mg of NOX66, respectively, following safety reviews. Data regarding safety, efficacy, pain scores, and QOL were collected. Results: 32 men were enrolled in cohorts 1&2 (November 2017 – June 2019) and 24 in cohort 3 (August 2019-February 2020). To date there have been no dose-limiting toxicities. Data for cohort 3 are immature. For cohorts 1 & 2: 31/32 men received ≥2 cycles, with 12/32 (47%) completing 6 cycles. Any PSA response was seen in 84% (27/32), with a PSA response > 50% in 62.5% (20/32). Median PSA PFS is 6.1 months Of men with increased baseline pain scores ≥3 (24/32), 50% (12/24) had a clinically significant reduction in pain indicators. Adverse events are summarized below. Updated results for cohorts 1 and 2 and preliminary results of cohort 3 will be presented. Conclusions: Combination LuPSMA-617 + NOX 66 appears safe and efficacious in men with heavily pre-treated end stage mCRPC. Clinical trial information: ACTRN12618001073291 .
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Affiliation(s)
- Louise Emmett
- Department of Theranostics and Nuclear Medicine, St. Vincent's Hospital, Sydney, Australia
| | | | - Megan Crumbaker
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Christopher Rofe
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Andrew On Wah Yam
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Bao Ho
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Wai Ling Chan
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Shikha Sharma
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Joanne Keane
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Adam James Hickey
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Karen Fullard
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Kamonwan Kongrak
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | - Lalith Ratnayake
- The Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, Australia
| | | | - Arun Azad
- Peter MacCallum Cancer Centre, Victoria, Australia
| | - Peter Eu
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Andrew Nguyen
- Department of Theranostics and Nuclear Medicine, St Vincent's Hospital, Sydney, Australia
| | - Anthony M. Joshua
- Kinghorn Cancer Centre, St Vincent's Hospital, Sydney, NSW, Australia
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Crumbaker M, Chan EKF, Gong T, Corcoran N, Jaratlerdsiri W, Lyons RJ, Haynes AM, Kulidjian AA, Kalsbeek AMF, Petersen DC, Stricker PD, Jamieson CAM, Croucher PI, Hovens CM, Joshua AM, Hayes VM. The Impact of Whole Genome Data on Therapeutic Decision-Making in Metastatic Prostate Cancer: A Retrospective Analysis. Cancers (Basel) 2020; 12:E1178. [PMID: 32392735 PMCID: PMC7280976 DOI: 10.3390/cancers12051178] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/21/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND While critical insights have been gained from evaluating the genomic landscape of metastatic prostate cancer, utilizing this information to inform personalized treatment is in its infancy. We performed a retrospective pilot study to assess the current impact of precision medicine for locally advanced and metastatic prostate adenocarcinoma and evaluate how genomic data could be harnessed to individualize treatment. METHODS Deep whole genome-sequencing was performed on 16 tumour-blood pairs from 13 prostate cancer patients; whole genome optical mapping was performed in a subset of 9 patients to further identify large structural variants. Tumour samples were derived from prostate, lymph nodes, bone and brain. RESULTS Most samples had acquired genomic alterations in multiple therapeutically relevant pathways, including DNA damage response (11/13 cases), PI3K (7/13), MAPK (10/13) and Wnt (9/13). Five patients had somatic copy number losses in genes that may indicate sensitivity to immunotherapy (LRP1B, CDK12, MLH1) and one patient had germline and somatic BRCA2 alterations. CONCLUSIONS Most cases, whether primary or metastatic, harboured therapeutically relevant alterations, including those associated with PARP inhibitor sensitivity, immunotherapy sensitivity and resistance to androgen pathway targeting agents. The observed intra-patient heterogeneity and presence of genomic alterations in multiple growth pathways in individual cases suggests that a precision medicine model in prostate cancer needs to simultaneously incorporate multiple pathway-targeting agents. Our whole genome approach allowed for structural variant assessment in addition to the ability to rapidly reassess an individual's molecular landscape as knowledge of relevant biomarkers evolve. This retrospective oncological assessment highlights the genomic complexity of prostate cancer and the potential impact of assessing genomic data for an individual at any stage of the disease.
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Affiliation(s)
- Megan Crumbaker
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Randwick, NSW 2031, Australia
- Kinghorn Cancer Centre, Department of Medical Oncology, St. Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
| | - Eva K. F. Chan
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Randwick, NSW 2031, Australia
| | - Tingting Gong
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- Central Clinical School, University of Sydney, Sydney, Camperdown, NSW 2050, Australia
| | - Niall Corcoran
- Australian Prostate Cancer Research Centre Epworth, Richmond, VIC 3121, Australia;
- Department of Surgery, University of Melbourne, Melbourne, VIC 3010, Australia
- Division of Urology, Royal Melbourne Hospital, Melbourne, VIC 3050, Australia
| | - Weerachai Jaratlerdsiri
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
| | - Ruth J. Lyons
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
| | - Anne-Maree Haynes
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
| | - Anna A. Kulidjian
- Department of Orthopedic Surgery, Scripps Clinic, La Jolla, CA 92037, USA.;
- Orthopedic Oncology Program, Scripps MD Anderson Cancer Center, La Jolla, CA 92037, USA
| | - Anton M. F. Kalsbeek
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
| | - Desiree C. Petersen
- The Centre for Proteomic and Genomic Research, Cape Town 7925, South Africa;
| | - Phillip D. Stricker
- Department of Urology, St. Vincent’s Hospital, Darlinghurst, NSW 2010, Australia;
| | - Christina A. M. Jamieson
- Department of Urology, Moores Cancer Center, University of California, San Diego, La Jolla, CA 92037, USA;
| | - Peter I. Croucher
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- School of Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, Randwick, NSW 2031, Australia
| | - Christopher M. Hovens
- Australian Prostate Cancer Research Centre Epworth, Richmond, VIC 3121, Australia;
- Department of Surgery, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Anthony M. Joshua
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Randwick, NSW 2031, Australia
- Kinghorn Cancer Centre, Department of Medical Oncology, St. Vincent’s Hospital, Darlinghurst, NSW 2010, Australia
| | - Vanessa M. Hayes
- Garvan Institute of Medical Research, Darlinghurst, NSW 2010, Australia; (M.C.); (E.K.F.C.); (T.G.); (W.J.); (R.J.L.); (A.-M.H.); (A.M.F.K.); (P.I.C.)
- St. Vincent’s Clinical School, University of New South Wales, Sydney, Randwick, NSW 2031, Australia
- Central Clinical School, University of Sydney, Sydney, Camperdown, NSW 2050, Australia
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Emmett L, Pathmanandavel S, Nguyen A, Crumbaker M, Yam AOW, Chan WL, Fullard K, Ho B, Azad A, Joshua AM. Results of a phase I/II prospective dose-escalation trial evaluating safety and efficacy of combination 177LuPSMA-617 and NOX66 in men with mCRPC post androgen signalling inhibition and two lines of taxane chemotherapy (LuPIN trial). J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.6_suppl.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
120 Background: Despite treatment advances, metastatic castrate resistant prostate cancer (mCRPC) remains a lethal disease. Trials in 177LuPSMA-617 have demonstrated good efficacy and safety, but synergistic combinations may further improve treatment responses. NOX66 inhibits external NADH oxidase type 2 with downstream pro-apoptotic actions including radio-sensitization. We present results of a prospective open label single arm phase 1/2 dose escalation/expansion trial of 177LuPSMA-617 and NOX66 in mCRPC. Methods: Men with progressive mCRPC post androgen signalling inhibition (ASI) and taxane chemotherapy were eligible. Inclusion criteria included PSMA PET/CT intensity > SUV max 15, with no discordant disease on FDG PET/CT, Hb > 100 g/L, Platelets > 90 x 106/L and GFR > 40 mL/min. Protocol allowed up to 6 doses of 177 Lu-PSMA 617 (7.5Gbq) on day 1 with NOX66 (suppository) given day 1-10 at 6-weekly intervals; the first 8 men received 400mg NOX66. After safety review, dose was escalated to 800mg. Data regarding safety, efficacy, pain scores, and QOL were collected. Results: 32/43 (26% imaging screen failures) screened men were enrolled (November 2017 – June 2019), of whom 100% had prior docetaxel and ASI, and 94% (30/32) cabazitaxel. All men received ≥ 2 cycles, with 12/32 completing 6 cycles, and 16/32 2 - 5 cycles, while 4/32 remain on treatment. Any PSA response was seen in 84% (27/32), with a PSA response > 50% in 62.5% (20/32). Median PSA PFS was 6.5 months (95%CI 3.54-9.3). To date, 72% (23/32) of patients have progressed. 34% (11/32) men have died with median OS not reached. 50% (12/24) of men with baseline pain scores ≥3 (24/32) had significant reduction in pain. Adverse events are summarized below. Conclusions: Combination 177LuPSMA-617 with NOX66 appears safe and efficacious in men with heavily pre-treated mCRPC. Clinical trial information: ACTRN12618001073291. [Table: see text]
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Affiliation(s)
- Louise Emmett
- St Vincent's Hospital Department of Nuclear Medicine, Sydney, Australia
| | | | | | | | | | | | | | - Bao Ho
- St Vincents Hospital, Sydney, Australia
| | - Arun Azad
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Anthony M. Joshua
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
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Crumbaker M, Emmett L, Horvath LG, Joshua AM. Exceptional Response to 177Lutetium Prostate-Specific Membrane Antigen in Prostate Cancer Harboring DNA Repair Defects. JCO Precis Oncol 2019; 3:1-5. [DOI: 10.1200/po.18.00237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Megan Crumbaker
- St Vincent’s Hospital, Kensington, New South Wales, Australia
- University of New South, Darlinghurst, New South Wales, Australia
- University of New South Wales, Kensington, New South Wales, Australia
| | - Louise Emmett
- St Vincent’s Hospital, Kensington, New South Wales, Australia
- University of New South Wales, Kensington, New South Wales, Australia
| | - Lisa G. Horvath
- St Vincent’s Hospital, Kensington, New South Wales, Australia
| | - Anthony M. Joshua
- St Vincent’s Hospital, Kensington, New South Wales, Australia
- University of New South, Darlinghurst, New South Wales, Australia
- University of New South Wales, Kensington, New South Wales, Australia
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Chen J, Joshua AM, Denmeade SR, Antonarakis ES, Crumbaker M. High dose testosterone in men with metastatic castrate-resistant prostate cancer (mCRPC) and homologous recombination deficiency (HRD). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.tps5095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS5095 Background: mCRPC progresses via adaptive mechanisms that allow ongoing androgen receptor (AR) signalling despite castrate levels of androgens. Bipolar androgen therapy (BAT), cycling between supraphysiologic and subphysiologic serum testosterone levels, aims to exploit these adaptations to induce tumor regression. Extensive clinical data demonstrate the safety and efficacy of BAT in men with asymptomatic mCRPC. However, de novo resistance is still common and predictive biomarkers to refine patient selection are lacking. Pre-clinical data suggest that the induction of double-stranded DNA (dsDNA) breaks by BAT may be crucial to its mechanism of action. DNA repair defects, such as HRD, are particularly relevant in CRPC patients. We hypothesize that CRPC patients with DNA repair deficits such as HRD, may be particularly responsive to BAT. Methods: This is a phase II prospective single arm interventional trial (NCT03522064). Up to 30 patients will be recruited based on a Simon two-stage design with a power of 90% to detect an increase in response rate from 20% to 40%. Key inclusion criteria include i) asymptomatic or minimally symptomatic mCRPC, ii) rising PSA despite a castrate serum testosterone and iii) HRD on germline, tumor and/or circulating tumor DNA (ctDNA) analysis. Key exclusion criteria include i) ADT < 1 year, ii) disease extent/sites that would cause significant risk if tumor flare occurs (e.g.: brain) and iii) significant cardiac disease. Previous PARP inhibitor therapy will be permitted in a subset. Participants will receive IM testosterone enanthate 500mg q4w in combination with ongoing LHRH antagonist/agonist or orchidectomy. The primary endpoint is PSA response rate defined as PSA reduction ≥50% from baseline. Secondary endpoints include time to PSA progression, quality of life, radiologic response and safety and tolerability. Exploratory endpoints include changes in ctDNA and tumoral DNA alterations from baseline to progression. Accrual is ongoing. Clinical trial information: NCT03522064.
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Affiliation(s)
- Julia Chen
- Kinghorn Cancer Centre, Sydney, NSW, Australia
| | - Anthony M. Joshua
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Samuel R. Denmeade
- Johns Hopkins University Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | | | - Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, Australia
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Arasaratnam M, Crumbaker M, Bhatnagar A, McKay MJ, Molloy MP, Gurney H. Inter- and intra-patient variability in pharmacokinetics of abiraterone acetate in metastatic prostate cancer. Cancer Chemother Pharmacol 2019; 84:139-146. [PMID: 31081533 DOI: 10.1007/s00280-019-03862-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 05/02/2019] [Indexed: 01/05/2023]
Abstract
PURPOSE This study examined the inter- and intra-patient variability in pharmacokinetics of AA and its metabolites abiraterone and Δ(4)-abiraterone (D4A), and potential contributing factors. METHODS AA administered daily for ≥4 weeks concurrently with androgen deprivation therapy (ADT) for mCRPC were included. Pharmacokinetic evaluation was performed at two consecutive visits at least 4 weeks apart. Plasma samples were collected 24 h after last dose of AA to obtain drug trough level (DTL) of two active metabolites, abiraterone and D4A. RESULTS 39 plasma samples were obtained from 22 patients, with 17 patients had repeat DTL measurement. Considerable inter-patient variability in DTL was seen, with initial DTL for abiraterone ranging between 1.5 and 25.4 ng/ml (CV 61%) and for D4A between 0.2 and 2.5 ng/ml (CV 61%). Intra-patient variability in DTL for abiraterone varied between 0.85 and 336% and for D4A between 1.14 and 199%. There was no increase in AA exposure with use of dexamethasone (n = 5; DTL 13.9) compared with prednisone (n = 17; DTL 11.0 p = 0.5), dosing in fasted state (n = 13, DTL 12.1) compared to dosing in fed state (n = 9; DTL 11.1, p = 0.8), or chemotherapy-exposed (n = 10; DTL 8.9) compared to chemotherapy naïve (n = 12; DTL 14.0, p = 0.1). CONCLUSIONS Our cohort demonstrated high inter- and intra-patient variability in both abiraterone and D4A with fixed dosing of AA, with no effect from choice of corticosteroids, prior use of chemotherapy, or dosing in fasting state. Monitoring DTL of AA may be necessary to minimise risk of patients being under-dosed and earlier development of resistance.
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Affiliation(s)
- Malmaruha Arasaratnam
- Department of Medical Oncology, Gosford Hospital, Sydney, Australia.
- Kolling Institute, The University of Sydney, Royal North Shore Hospital, Sydney, Australia.
- Gosford Hospital, Holden St, Gosford, NSW, 2250, Australia.
| | - Megan Crumbaker
- Department of Medical Oncology, The Kinghorn Cancer Centre, Sydney, Australia
| | - Atul Bhatnagar
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
| | - Matthew J McKay
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
| | - Mark P Molloy
- Kolling Institute, The University of Sydney, Royal North Shore Hospital, Sydney, Australia
- Department of Molecular Sciences, Macquarie University, Sydney, Australia
| | - Howard Gurney
- Department of Medical Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, Australia
- Macquarie University Clinic, Macquarie University Hospital, Sydney, Australia
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37
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Crumbaker M, Wong J, Joshua AM, Spigelman AD. Outcomes of universal germline testing for men with prostate cancer in an Australian tertiary center. Asia Pac J Clin Oncol 2019; 15:257-261. [PMID: 31012270 DOI: 10.1111/ajco.13148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 03/02/2019] [Indexed: 11/27/2022]
Abstract
AIM The role of germline testing in prostate cancer is evolving and knowledge of an individual's genetic profile may be used to guide not only an assessment of their familial risk but also have prognostic and therapeutic implications. Although international guidelines have incorporated recommendations for germline testing in prostate cancer, there is little Australian data to guide referrals. The aim of this study is to review the frequency of relevant pathogenic mutations in an Australian center, their associated clinical factors and clinical impact. METHODS We conducted a single-center retrospective review of men with prostate cancer that undertook prospective germline testing using a targeted next generation sequencing panel. RESULTS Results for 100 men were analyzed. Median age at diagnosis was 62 years (range 43-84); 92% had metastatic disease at referral. A pathogenic mutation was confirmed in 9%, a likely pathogenic variant in 2% and a variant of uncertain significance in 15%. Age ≤60 years was associated with an increased risk for a pathogenic germline variant (P = 0.0096). Two of the nine (22%) with pathogenic variants went on to receive targeted treatment. CONCLUSIONS In this single center study, the incidence of germline mutations in genes associated with DNA-repair was consistent with rates seen previously published international series of men with metastatic disease. A pathogenic variant was only seen in one patient >60 years of age and no man referred solely on the basis of age or high-risk localized disease had a relevant finding.
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Affiliation(s)
- Megan Crumbaker
- Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,University of New South Wales, St. Vincent's Clinical School, Darlinghurst, NSW, Australia
| | - Jean Wong
- Department of Surgery, St. Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Anthony M Joshua
- Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,Garvan Institute of Medical Research, Darlinghurst, NSW, Australia.,University of New South Wales, St. Vincent's Clinical School, Darlinghurst, NSW, Australia
| | - Allan D Spigelman
- Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, St. Vincent's Clinical School, Darlinghurst, NSW, Australia.,Cancer Genetics Unit, St. Vincent's Hospital, Darlinghurst, NSW, Australia
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Emmett L, Crumbaker M, Ho B, Willowson K, Eu P, Ratnayake L, Epstein R, Blanksby A, Horvath L, Guminski A, Mahon K, Gedye C, Yin C, Stricker P, Joshua AM. Results of a Prospective Phase 2 Pilot Trial of 177Lu–PSMA-617 Therapy for Metastatic Castration-Resistant Prostate Cancer Including Imaging Predictors of Treatment Response and Patterns of Progression. Clin Genitourin Cancer 2019; 17:15-22. [DOI: 10.1016/j.clgc.2018.09.014] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 09/20/2018] [Indexed: 10/28/2022]
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39
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Emmett L, Yin C, Crumbaker M, Hruby G, Kneebone A, Epstein R, Nguyen Q, Hickey A, Ihsheish N, O’Neill G, Horvath L, Chalasani V, Stricker P, Joshua AM. Rapid Modulation of PSMA Expression by Androgen Deprivation: Serial 68Ga-PSMA-11 PET in Men with Hormone-Sensitive and Castrate-Resistant Prostate Cancer Commencing Androgen Blockade. J Nucl Med 2018; 60:950-954. [DOI: 10.2967/jnumed.118.223099] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 11/28/2018] [Indexed: 12/23/2022] Open
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40
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Arasaratnam M, Balakrishnar B, Crumbaker M, Turner S, Hayden A, Brooks A, Patel M, Gurney H. Patterns of care and outcome of germ cell tumours (GCT) in an Australian high-volume centre. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.e16534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Crumbaker M, Joshua AM, Epstein R, Emmett L. A phase I study of 177Lu-DKFZ PSMA 617 combined with the radiosensitizer idronoxil in men with metastatic castrate-resistant prostate cancer (mCRPC) (LuPin trial). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.15_suppl.tps5088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Megan Crumbaker
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Darlinghurst, Australia
| | - Anthony M. Joshua
- The Kinghorn Cancer Centre, St. Vincent's Hospital, Sydney, Australia
| | - Richard Epstein
- The Kinghorn Cancer Centre, St Vincent’s Hospital, Sydney, Australia
| | - Louise Emmett
- St Vincent's Hospital Department of Nuclear Medicine, Sydney, Australia
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Crumbaker M, Savdie R, Joshua AM. Refining the Assessment and Implications of AR-V7 in Castrate-resistant Prostate Cancer. Eur Urol 2018; 73:736-737. [DOI: 10.1016/j.eururo.2017.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
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Abstract
Despite a growing number of treatment options, metastatic castrate resistant prostate cancer remains almost universally fatal. Dose individualization ensures patients receive the maximal benefit from each line of treatment potentially leading to improved outcomes, a reduction in quality of life impairment and minimization of premature cessation for avoidable toxicity. Herein, we review drug-specific issues that may be associated with unexpected or unrecognized variations in drug systemic exposure despite the use of protocol doses. In particular, we discuss the potential for under-exposure of docetaxel and cabazitaxel; over-exposure of enzalutamide; and varied absorption of abiraterone acetate.
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Affiliation(s)
- Megan Crumbaker
- Crown Princess Mary Cancer Care Centre, Westmead Hospital, New South Wales, Australia
- Kinghorn Cancer Centre, Darlinghurst, New South Wales, Australia
- Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Howard Gurney
- Crown Princess Mary Cancer Care Centre, Westmead Hospital, New South Wales, Australia
- Macquarie University, New South Wales, Australia
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Crumbaker M, Guminski A, Gurney H, Sabanathan D, Wong S, Pavlakis N. Real-world experience of the feasibility and tolerability of the 2/1 dosing schedule with sunitinib in the treatment of patients with advanced renal cell carcinoma in Australia. Asia Pac J Clin Oncol 2017; 14:e45-e49. [PMID: 28429452 DOI: 10.1111/ajco.12686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 02/27/2017] [Indexed: 11/26/2022]
Abstract
AIM Sunitinib is a first-line treatment option for metastatic renal cell carcinoma (mRCC) funded by the Australian Pharmaceutical Benefits Scheme. Toxicities are common with the standard schedule leading to alternative dosing schedules to be suggested. We reviewed Australian treatment practices to evaluate the safety and outcomes of patients on a 2 weeks on, 1 week off treatment schedule (2/1). METHODS We performed a retrospective review of 63 patients with mRCC treated with first-line sunitinib on a 2/1 schedule at four Australian centers. RESULTS Forty-six patients (73%) initiated sunitinib on the 2/1 schedule whereas 17 (27%) switched from the 4/2 schedule due to toxicity. Three progressing on a 4/2 schedule tolerated up-titration of their dose with a clinical and radiological response on the 2/1 schedule. The median duration of treatment was 31.9 months; median duration of treatment on the 2/1 schedule in patients changing from 4/2 was 11.5 months. Few (6.3%) ceased due to toxicity. Median overall survival was 37.2 months. CONCLUSION In this retrospective review of the 2/1 sunitinib schedule, time on treatment with clinical benefit exceeded the overall survival times seen in the phase III trials utilizing the 4/2 schedule. Overall survival also exceeded that seen in these trials. Few patients ceased due to toxicity. The 2/1 schedule appears to be an acceptable schedule to use in selected patients with mRCC both at initiation of first-line treatment and in those intolerant to the 4/2 schedule.
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Affiliation(s)
- Megan Crumbaker
- Royal North Shore Hospital, NSW, Australia.,Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Australia
| | | | - Howard Gurney
- Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Australia
| | | | | | - Nick Pavlakis
- Royal North Shore Hospital, NSW, Australia.,Northern Cancer Institute, NSW, Australia
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Crumbaker M, Khoja L, Joshua AM. AR Signaling and the PI3K Pathway in Prostate Cancer. Cancers (Basel) 2017; 9:cancers9040034. [PMID: 28420128 PMCID: PMC5406709 DOI: 10.3390/cancers9040034] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 04/04/2017] [Accepted: 04/11/2017] [Indexed: 12/20/2022] Open
Abstract
Prostate cancer is a leading cause of cancer-related death in men worldwide. Aberrant signaling in the androgen pathway is critical in the development and progression of prostate cancer. Despite ongoing reliance on androgen receptor (AR) signaling in castrate resistant disease, in addition to the development of potent androgen targeting drugs, patients invariably develop treatment resistance. Interactions between the AR and PI3K pathways may be a mechanism of treatment resistance and inhibitors of this pathway have been developed with variable success. Herein we outline the role of the PI3K pathway in prostate cancer and, in particular, its association with androgen receptor signaling in the pathogenesis and evolution of prostate cancer, as well as a review of the clinical utility of PI3K targeting.
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Affiliation(s)
- Megan Crumbaker
- Kinghorn Cancer Centre, St Vincent's Hospital, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia.
- Garvan Institute of Medical Research, St Vincent's Clinical School, University of New South Wales, Sydney, 384 Victoria St, Darlinghurst, Sydney, NSW 2010, Australia.
| | - Leila Khoja
- AstraZeneca UK, Clinical Discovery Unit, Early Clinical Development Innovative Medicines, da Vinci Building, Melbourn Science Park, Melbourn, Hertfordshire SG8 6HB, UK.
- Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust Cambridge Biomedical Campus, Hills Rd, Cambridge CB2 0QQ, UK.
| | - Anthony M Joshua
- Kinghorn Cancer Centre, St Vincent's Hospital, 370 Victoria Street, Darlinghurst, Sydney, NSW 2010, Australia.
- Garvan Institute of Medical Research, St Vincent's Clinical School, University of New South Wales, Sydney, 384 Victoria St, Darlinghurst, Sydney, NSW 2010, Australia.
- Princess Margaret Cancer Centre, University Health Network, University of Toronto, University Avenue, Toronto, ON M5G 2M9, Canada.
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Mersiades A, Crumbaker M, Gao B, Nagrial A, Hui R. P3.02c-033 Patterns of Progression and Management of Acquired Resistance to Anti-PD-1 Antibodies in Advanced Non-Small Cell Lung Cancer. J Thorac Oncol 2017. [DOI: 10.1016/j.jtho.2016.11.1828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Crumbaker M, Carlino M, Hui R, Mersiades A, Gurney H, Todd J, Gao B, Nagrial A. 471P Baseline full blood count parameters as predictors of response to PD-1 inhibition in advanced NSCLC. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw594.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Chan D, McLachlan JM, Crumbaker M, Marx GM. Pretreatment neutrophil/lymphocyte ratio (NLR) prior to steroids as a prognostic factor in metastatic castrate refractory prostate cancer (mCRPC) patients treated with taxanes. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.7_suppl.273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
273 Background: The neutrophil/lymphocyte ratio (NLR) has been demonstrated to be a prognostic factor in multiple malignancies. Prior analyses have demonstrated conflicting results in correlation between NLR and overall survival (OS) in mCRPC. Prednisone and dexamethasone, commonly used in chemotherapy regimens for prostate cancer, have been demonstrated to affect neutrophils and hence NLR. We investigated the correlation between pre-dexamethasone NLR and OS in patients with mCRPC. Methods: We performed a retrospective single-center study of patients with mCRPC who received taxane-based chemotherapy (docetaxel or cabazitaxel) between 9/2005 and 12/2012. Patients were included if blood test results were available between 3 and 28 days prior to commencement of chemotherapy. Baseline demographics and NLR were correlated with OS using a Cox proportional hazards model. Results: 42 patients were included, 9 of whom were still alive, with median age 70 and median follow-up 23.1 months. Median OS was 24.1 months. 36 were commenced on docetaxel-based chemotherapy and 6 on cabazitaxel-based chemotherapy. Considering NLR as a categorical variable, OS was significantly better in patients with NLR<5 (n=28) compared to those with NLR>5 (n=14), with median OS 32mo vs 15.4mo and HR 2.155 (95% CI 1.072-4.332, p=0.0007 by log-rank test). In multivariate analyses, NLR (p=0.008) and age (p=0.048) were independent predictors of overall survival. In sensitivity analyses, when including NLRs within 48 hours of chemotherapy initiation, the correlation between NLR and OS was only marginally significant (p=0.048). Conclusions: HighNLR is an adverse prognostic marker for decreased overall survival in mCRPC patients undergoing taxane-based chemotherapy. Previous conflicting results regarding its value may be related to the effect of steroids on NLR.
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Affiliation(s)
- David Chan
- Royal North Shore Hospital, St. Leonards, Australia
| | | | | | - Gavin M. Marx
- Northern Haematology and Oncology Group, Sydney, Australia
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