Prognostic Value of the Levels of Circulating Tumor Cells (CTCs) in Peripheral Blood in Patients With Prostate Cancer at High Risk (Clinical Stages IIB-III) Treated Radically With Radiotherapy and Hormone Therapy.
Conditions: Patients With High-risk Prostate Cancer
Sponsor: Fundación de Investigación Biomédica - Hospital Universitario de La Princesa

Almudena Zapatero MD, PhD – Radiation Oncology Department 
HOSPITAL UNIVERSITARIO DE LA PRINCESA 
Prognostic value of the levels of circulating tumor cells 
(CTCs) in peripheral blood in patients with prostate 
cancer at high risk (Clinical Stages IIB-III) treated 
radically with radiotherapy and hormone therapy 
 
Unique Protocol ID: CaPr-RTCTC-01/PI 197 
Version 2, October 10th 2012 
 
NTC01800058 
 
 

Prognostic value of the levels of circulating tumor cells (CTCs) in 
peripheral blood in patients with prostate cancer at high risk (Clinical 
Stages IIB-III) treated radically with radiotherapy and hormone 
therapy. 
HYPOTHESIS: 
The detection and quantification of Circulating tumor cells CTCs in peripheral 
blood of patients with prostate adenocarcinoma may be useful at least for: 
- Getting a correct stratification of patients with high-risk prostate cancer 
(PCa). 
- Set the prognosis at baseline. 
- Evaluate the response to different treatments (predictive value and 
monitoring). 
- Establish individualized therapies. 
 
MAIN AIM: 
Primary Objective:  
To evaluate the proportion of patients with high-risk prostate cancer (NCCN 
2011), IIB-III AJCC staging, that expresses circulating prostatic tumor cells 
(CTCs) in the peripheral blood (PB). 
 
SECONDARY AIMS: 
To establish whether the expression of CTCs a) following neoadjuvant androgen 
deprivation (AD) prior to radiotherapy (RT) and b) following RT, predict for 
biochemical relapse, overall survival and distant metastasis. 
 
METHODOLOGY: 
Prospective analysis of biologic samples from peripheral blood of 65 patients with 
localized high-risk PCa (NCCN 2011) treated with RTC-3D-IMRT combined with 
AD. 
Following the sign of the informed consent of the patient, the blood samples will 
be analyzed for CTCs using an immunomagnetic method based on the 
CellSearch system (Veridex), in 3 periods of time:  
a) prior to any treatment;  
b) Following AD and prior to RT; and  
c) Following the end of RT (1-3 months afterwards). 

4) 6-12 months following the end of RT in those patients with 0 CTCs in 
the first determination and positive CTCs in the following determinations. 
A cut off of 0 vs ≥ 1CTCs/7.5 mL blood was defined as a threshold for 
negative versus positive CTCs status. 
 
Comparison between the expression of CTCs in peripheral blood before and 
following AD and RT will be performed. The quantification of the CTCs obtained 
in these phases of treatment will be correlated with the treatment results in terms 
of biochemical failure according to Phoenix definition, distant metastasis rate and 
overall survival to identify a significant prognostic relationship and to determine 
the potential effect of the treatment in the number of CTCs 
Our working group will include 65 patients because the amount is based on 
routine clinical activity can be safely enrolled in the project development time by 
the participating centers. 
 
NUMBER OF PATIENTS:  
65 patients 
 
CONDITION: 
This research project will take place in the context of clinical practice, without the 
need of complementary extras or additional visits. Treatment given standard 
treatment is recommended in clinical practice guidelines. Finally, the extraction 
of 7.5 ml of blood needed will be in the same procedure as usual veno-puncture 
for clinical testing for the diagnosis and monitoring of patients. 
After obtaining informed consent shall be the removal of SP samples (7.5 ml) for 
detection of CTCs by immunomagnetic method based on the CellSearch system 
(Veridex) in three time periods: 
a) Prior to the start of any treatment-DA initially neoadjuvant 
b) Prior to the start of RT (DA after neoadjuvant) 
c) At the end of RT (1-3 months) 
 
The analysis-quantification of CTCs obtained in these phases, will correlate with 
treatment outcomes in terms of biochemical failure (BF) according to the criteria 
of Phoenix 2006 and overall survival to identify potential prognostic value. 
Likewise determinations are compared before and after CTCs DA and RT to 
evaluate the effect of such treatments on modular quantifying CTCs 

The assignment of a patient to a particular therapeutic strategy is independent 
prior to the decision to include the patient in the study. The study period is after 
the start of the investigation. 
 
INTERVENTION: 
This is a multicenter, prospective, observational, single-arm, phase IV. 
Prospective analysis of biological material from samples of peripheral blood (PB) 
of patients diagnosed with prostate cancer at high risk (NCCN 2011), AJCC stage 
IIB-III, treated with 3D-CRT, IMRT dose escalation (with androgen deprivation 
(DA)) 
After obtaining informed consent shall be the sampling of peripheral blood (PB) 
for detection of CTCs in three treatment periods: 
    - Before starting any treatment-DA initially neoadjuvant 
    - Prior to the start of RT (DA after neoadjuvant) 
    - At the end of RT (1-3 months) 
The analysis-quantification of CTCs obtained in these phases, will correlate with 
treatment outcomes in terms of biochemical failure (BF) according to the criteria 
of Phoenix 2006 and overall survival and metastasis-free to identify potential 
prognostic value. Likewise determinations are compared before and after CTCs 
DA and RT to evaluate the effect of such treatments on modular quantifying CTCs 
(predictive value). 
 
PHASE: 
A multicenter, prospective, observational, single-arm, phase IV.  
 
STUDY TYPE: STUDY DESIGN: 
A multicenter, prospective, observational, single-arm, phase IV.  
Prospective analysis of biological material from samples of peripheral blood (PB) 
of 65 patients diagnosed with prostate cancer at high risk (NCCN 2011), AJCC 
stage IIB-III, treated with 3D-CRT, IMRT dose escalation and androgen 
deprivation (DA). 
 
OFFICIAL TITLE:  
Prognostic value of the levels of circulating tumor cells (CTCs) in peripheral blood 
in patients with prostate cancer at high risk (Clinical Stages IIB-III) treated 
radically with radiotherapy and hormone therapy. ” Ref.: CaPr-RTCTC-01/PI 197 

 
PRIMARY OUTCOME MEASURE: 
The expression of circulating tumor cells in the peripheral blood of patients with 
high-
circulating cells per 7.5 ml of blood will be taken as the reference baseline). 
 
SECUNDARY OUTCOME MEASURES: 
- Radiation dose 
- Duration and type of hormone therapy 
- Gleason sum 
- Pretreatment PSA 
- Clinical T stage 
- Biochemical failure-free survival (“Phoenix definition”: PSA ≥ 2 ng/ml over the 
nadir PSA). 
- Overall Survival defined as death due to any cause 
- Metastasis-free survival defined as imaging documented evidence of distant 
spread of disease; 
 
ARMS: 
Not applicable 
 
ASSIGNED INTERVENTIONS: 
The experimental approximations that will be develop in this project are 
enumerated below:  
Patients that satisfy inclusion criteria, and after signing informed consent, will 
extract 1 blood sample (7.5 mL): 
a) prior to any treatment;  
b) Following AD and prior to RT; and  
c) Following the end of RT (1-3 months afterwards). 
4) 6-12 months following the end of RT in those patients with 0 CTCs in the first 
determination and positive CTCs in the following determinations. A cut off of 0 vs 
≥ 1CTCs/7.5 mL blood was defined as a threshold for negative versus positive 
CTCs status. 
 

The quantification of CTC in blood samples will be done with the CellSearch® 
system. 
 
ELIGIBILITY: 
AGES ELIGIBLE FOR STUDY: 
Patients aged > 18 
 
GENDERS ELIGIBLE FOR STUDY: 
Male 
 
INCLUSION CRITERIA: 
 Patients aged > 18 with capacity to give informed consent. 
  Patients with histologically confirmed prostate cancer. 
  Patients with a high risk factor: PSA> 20 ng / ml, Gleason 8-10 and / or 
stage T3a-b, N0M0 (NCCN 2011, stage IIB-III AJCC classification 2010). 
Staging by: Histology-Gleason score-, PSA, TR, ECO TR, CT, MRI. 
 Patients who accept radical treatment with radiotherapy. 
 Patients who give written informed consent to participate in the study. 
 
EXCLUSION CRITERIA: 
a) Any patient diagnosed with prostate cancer, which does not meet the 
prerequisites. 
b) Any patients with another malignancy diagnosed in the past 5 years (except 
basal cell or squamous cell carcinoma of skin). 
c) Any patient who has prostate biopsy performed 7 days prior to study entry. 
d) Patients who have received prior treatment with hormonal therapy, 
chemotherapy or radiotherapy. 
e) Patients with PSA> 100 ng / ml. 
f) Any situation or condition of the patient which in the opinion of the investigator, 
advised against participation in the study.  
 
STATISTICAL METHODS 
The frequency of expression of CTCs was estimated with its 95% confidence 
interval (CI). Initially a cutoff point of ≥3 CTCs/7.5 mL of blood was taken as the 

reference baseline. Because of the low CTC counts observed and for statistical 
purposes, we empirically established a cut-off of 0 vs ≥1 CTCs/7.5 mL blood as 
the thresholds between negative and positive CTC status. The association 
between the presence and development of CTCs over time and well-known 
clinicopathological features was assessed using the 2 test or Fisher exact test. 
Overall survival, metastasis-free survival, and biochemical failure–free survival 
were estimated using the Kaplan-Meier method. The curves were compared 
using the log-rank test. All events were defined as time until death from any cause 
(OS), distant metastasis (MFS), biochemical failure (bFS), or date of last follow-
up visit. Cox regression models were constructed to estimate the hazard ratio 
and 95% CI as a measure of the effect and were adjusted for potential 
confounding variables (P ≤ 0.20)..All hypothesis tests were performed using 2-
tailed alternatives. Statistical significance was set at P < 0.05. 
 
CONTACTS AND LOCATION: 
Almudena Zapatero, MD PhD, IP 
Hospital Universitario de la Princesa 
Radiation Oncology Department 
C/Diego de León, 62 
Madrid 28006 
E-mail: azapatero.hlpr@salud.madrid.org 
 
PUBLICATIONS: 
1. 
D’Ambert JE. Prostate cancer. Lancet 2008; 371:1710-21 
2. 
Zelefsky MJ, Yamada Y, Fuks Z, et al. Long-term results of conformal 
radiotherapy for prostate cancer: Impact of dose escalation on biochemical tumor 
control and distant metastases-free survival outcomes. Int J Radiat Oncol Biol 
Phys 2008;71:1028–1033. 
 
3. 
KubanDA, Tucker SL, Dong YL, et al. Long-term results of the M.D. 
Anderson randomized dose-escalation trial for prostate cancer. Int J Radiat Oncol 
Biol Phys 2008;70:67–74. 
4. 
Roach M 3rd, Bae K, Speight J, et al. Short-term neoadjuvant androgen 
deprivation therapy and external-beam radiotherapy for locally advanced prostate 
cancer: Long-term results of RTOG 8610. J Clin Oncol 2008;26:585–591. 
5. 
Bolla M, Collette L, Van Tienhoven G, et al. Ten-year results of long-term 
adjuvant androgen deprivation with goserelin in patients with locally advanced 
prostate cancer treated with radiotherapy: A phase III EORTC study. Int J Radiat 
Oncol Biol Phys 2008;72:S30–S31. 
6. 
Horwitz EM, Bae K, Hanks GE, et al. Ten-year follow-up of Radiation 
Therapy Oncology Group protocol 92-02: A phase III trial of the duration of 

elective androgen deprivation in locally advanced prostate cancer. J Clin Oncol 
2008;26:2497–2504. 
7. 
A. Cabanes, E. Vidal, N. Aragones, B. Perez-Gomez, M. Pollan,  V. Lope 
et al. Cancer mortality trends in Spain: 1980–2007. Annals of Oncology 21 
(Supplement 3): iii14–iii20, 2010. 
8. 
L. Resel Folkersma, C. Olivier Gómez, L. San José Manso, et al. 
Cuantificación Inmunomagnética De Células Tumorales Circulantes En 
Pacientes Con Cáncer De Próstata: Correlación Clínica Y Patológica. Arch. Esp. 
Urol. 2010; 63 (1): 23-31 
9. 
Ghossein RA, Bhattacharya S and Rosai J. Molecular detection of 
micrometastases and circulating tumor cells in solid tumors. Cin Cancer Res 
1999; 5:1950-60. 
10. 
Llanes L, Ferruelo A, Lujan M, et aol. Quantitative real-time reverse 
transcription: polymerase chain reaction of prostate-specific antigen for detection 
of circulating prostatic cells in patients with clinically localized prostate cancer. 
Prostate Cancer and Prostatic diseases 2005; 8:248-52. 
11. 
A Zapatero, F Valcárcel, F A Calvo, et al. Risk-adapted androgen 
deprivation and escalated 3D-Conformal radiotherapy for prostate cancer: Does 
radiation dose influence outcome of patients treated with adjuvant androgen 
deprivation? Report of a multicenter trial (GICOR 05/99). J Clin Oncol 
2005;23:6561-6568.   
12. 
 Roach M III, Hanks G, Thames H Jr., et al. Defining biochemical failure 
following radiotherapy with or without hormonal therapy in men with clinically 
localized prostate cancer: Recommendations of the RTOG-ASTRO Phoenix 
Consensus Conference. Int J Radiat Oncol Biol Phys 2006;65:965–974. 
13. 
Cristofanilli M, Budd T, Ellis MJ, Stopeck A, Matera J, Miller MC et al. 
Circulating tumor cells, disease progresión, and survival in metastatic breast 
cancer. N Engl J Med 2004; 351:781-91. 
14. 
Shaffer DR, Leversha MA, Danila DC, Lin O, Gonzalez-Espinoza R, Gu B 
et al. Circulating tumor cell analysis in patients with progresive castration-
resistant prostate cancer. Clin Cancer Res 2007; 13(7):2023-29. 
15. 
Almudena Zapatero,  Mario A. López, Alicia Marín, Ricardo Mínguez, 
Feliciano García-Vicente. Dose-escalation with three-dimensional conformal 
radiotherapy for prostate cancer.  Is more dose really better in high-risk patients 
treated with androgen deprivation? Clin Oncol 2006.18:600-607   
16. 
Moreno JG, Miller MC, Gross S, Allard WJ, Gomella LG and Terstappen 
LW. Circulating tumor cells predict survival in patients with metastatic prostate 
cancer. Urology 2005; 65:713-18. 
17. 
Fehm T, Sagalowsky A, Clifford E, Beitsch P, Saboorian H, Euhus D et al. 
Cytogenetic evidence that circulating epithelial cells in patients with carcinoma 
are malignant. Clin Cancer Res 2002; 8:2073-84. 
18. 
Almudena Zapatero, Ricardo Mínguez, Santiago Nieto, Carmen Martín De 
Vidales, Feliciano García-Vicente. Post-Treatment Prostate Biopsies In The Era 
Of Three-Dimensional Conformal Radiotherapy. What Can They Teach Us? Eur 
Urol. 2009;55(902-910. 
19. 
A. Zapatero, F. García-Vicente, C. Martín De Vidales, et al. Long-Term 
Results After High-Dose Radiotherapy And Adjuvant Hormones In Prostate 
Cancer: How Curable Is High-Risk Disease? IntJRadiatOncol BiolPhys2010 Oct 
5. [Epub ahead of print] PMID:20932659[PubMed]     

20. 
C. Olivier Gómeza y J. Carballido Rodríguez. Circulating tumor cells: 
Isolation, quantification, and relevante of their translation into clinical practice. 
actas urol esp. 2010;34(1):3-5. 
21. 
Alix-Panabières C, Riethdorf S, Pantel K. Circulating tumor cells and bone 
marrow micrometastasis. Clin Cancer Res. 2008;14(16):5013-21. 
22. 
Mocellin S, Keilholz U, Rossi CR, Nitti D. Circulating tumor cells: the 
‘leukemic phase’ of solid cancers. Trends Mol Med. 2006;12(3):130-9. 
 
RESPONSIBLE PARTY:  
Almudena Zapatero , MD PhD, PI - Promotor 
Hospital Universitario de la Princesa 
C/Diego de León, 62 
Madrid 28006 
E-mail: azapatero.hlpr@salud.madrid.org 
ID NUMBERS: 
 
HEALTH AUTORITIES:  
Mª Rosario Ortiz de Urbina Barba 
Director Manager Fundación Investigación Biomédica IIS 
Hospital Universitario de la Princesa 
C/ Diego de León, 62 
28006 Madrid  
E-mail: mrosario.ortizurbina@salud.madrid.org