Patient case: 70-year-old male with prostate cancer; genetic feature: PTEN

Clinical trial: Radiologically Guided Biopsies of mCRPC

Summary: The purpose of this study is to better understand how cancer treatment may affect cancer cells. The research will involve genetic, molecular, cellular, and immunologic experiments using blood and tumor specimens. It is hoped that the information gained from these studies will lead to a greater understanding of castrate-resistant prostate cancer and potentially, improvements in cancer treatment.
  This is a tissue collection protocol requiring image-guided biopsies of metastatic, castration-resistant prostate cancer (mCRPC). The investigators will focus on enrolling patients with metastatic CRPC who have progressed while receiving novel AR-targeted therapeutics such as abiraterone and enzalutamide. This population of patients was selected because resistance develops relatively rapidly following potent inhibitors of AR activity and the mechanisms of resistance have to be better understood. Without comprehensive analysis of mCRPC tumor, the investigators will never gain a full understanding of the biology driving resistance in human disease and developing rational co-targeting approaches will not be possible.


Eligibility: Inclusion Criteria:
  -  History of histologically confirmed prostate cancer. Patients without histologically confirmed prostate cancer are eligible if both the treating physician and the study PI agree that the patient's history is unambiguously indicative of advanced prostate cancer (e.g. high PSA responsive to Androgen Deprivation Therapy.)
  -  Radiographic evidence of metastatic disease amenable to image-guided biopsy of a metastatic site. Soft-tissue as well as bony metastatic lesions will be considered acceptable. Patients with locally advanced disease only (where the biopsy would be of a prostatic mass) are not eligible. Biopsy of newly emerging radiographic metastases is desired and preferable to the biopsy of previously existing lesions whenever possible.
  -  Platelets >75,000/μl within 14 days prior to biopsy
  -  PT or INR and a PTT < 1.5 times the institutional ULN within 14 days prior to biopsy.
  -  Patients on warfarin, aspirin, or other anti-coagulants are eligible provided they are deemed able to tolerate discontinuation of anti-coagulation for one week prior to the biopsy. Conversion to low molecular weight heparin prior to biopsy is permitted per local standard operating procedures, provided there is agreement regarding the procedure between the treating physician, the interventional radiologist and the PI.
  -  Castrate levels of testosterone (testosterone <50ng/dL) within 28 days prior to biopsy.
  -  Patients with significant congenital or acquired bleeding disorders (eg von Wildebrand's disease, acquired bleeding factor inhibitors) are not eligible.
  -  If no prior orchiectomy, medical castration therapy must continue while on study.
  -  PSA level obtained within 28 days prior to biopsy.
  -  Patients currently on first generation oral anti-androgens (flutamide, bicalutamide, nilutamide) must have progressed after at least 4 weeks of anti-androgen discontinuation.
  -  Patient's disease is currently progressing (in setting of testosterone < 50 ng/dl), defined by any of the following criteria:
  -  PSA Progression: PSA level of at least 2 ng/ml which has risen on at least 2 successive occasions, at least one week apart. If the confirmatory PSA (#3) value is less (i.e., #3b) than the screening PSA (#2) value, then an additional test for rising PSA (#4) will be required to document progression for the purposes of eligibility.
  -  Soft tissue progression: by RECIST v1.1
  -  Bone scan progression: the appearance of ≥ 2 new lesions. Symptomatic progression in an area of radiologically evident diseas
  -  One of the following criteria must be met:
  -  Evidence of disease progression (as defined above) following treatment with at least 2 months of abiraterone acetate, enzalutamide, or ARN509 - based therapy.
  -  Enrollment on a high priority clinical trial conducted by the WCDT. Examples include trials with biopsy obtained before abiraterone or enzalutamide therapy, and following development of resistance to those agent(s). This list is maintained by the lead site.
  -  Evidence of disease progression (as defined above) in patients with "aggressive phenotype" mCRPC with at least one of the following clinical features
  -  Visceral or brain metastases
  -  Known small cell or neuro-endocrine subtypes (by IHC or serum markers)
  -  Primary ADT resistance defined as a nadir PSA of > 4 ng/dl after 7 months of primary androgen deprivation (with Testosterone < 50 ng/dl.)
  -  Prior chemotherapy for Castration Resistant Prostate Cancer is not allowed
  -  Age > 18 yrs
  -  ECOG Performance status 0-3 (see appendix A)
  -  Ability to understand and the willingness to sign a written informed consent document

Relevance to patient case: not relevant