Abstract LB201: Optimizing adeno-associated viral vector-mediated delivery of trastuzumab to the central nervous system for the treatment of Her2 positive brain metastasis
Authors: Werner Marcela Salazar , Aras Shweta , Morgan Ashleigh , Param Nesteene J. , Greig Jenny , Wilson James M. 
Published: June 2022

Abstract
Breast cancer is the most common cause of brain metastases in women, affecting 15-30% of all patients. Despite the success of systemic Her2-targeted therapies, up to half of patients with Her2+ primary breast cancer develop breast cancer brain metastases (BCBM). Subtype switching from Her2- primary breast tumors account for an additional 15% of Her2+ BCBM, bringing total Her2 positivity in the BCBM setting to nearly 65% of cases. Even though direct delivery of Her2-targeted therapies to the central nervous system (CNS) has shown promising clinical results, long-term feasibility is limited, at least in part, by the need for repeated dosing to overcome the shorter drug half-life in the cerebrospinal fluid vs. systemic circulation (e.g., ~1 vs. 5 days, respectively). To achieve sustained CNS expression of trastuzumab without frequent dosing, we developed a gene therapy approach to treat BCBM comprising a single local administration of AAV vector encoding trastuzumab. Previous work from our group has shown that intracerebroventricular (ICV) injection of trastuzumab-expressing AAV doubled the life expectancy of Rag1 knockout (KO) mice bearing BT-474 breast cancer brain tumors. Rag1 KO mice who received AAV-trastuzumab prior to implantation of BT-474 tumor cells into the brain showed a dose-dependent delay in tumorigenesis. Following these proof-of-concept studies, we performed extensive gene therapy vector optimization and in vivo evaluation. The concentration of trastuzumab achieved in the brain parenchyma after a single ICV administration of the optimized vectors into Rag1 KO mice ranged from 10-165 ng/mg of brain protein by day 28. Previous studies utilizing CNS delivery of gene therapy vectors have shown vector leakage into the systemic circulation, which results in detectable transgene expression in the blood following peripheral transduction. To mitigate the potential risk of trastuzumab-induced cardiotoxicity, we investigated using intravenously administered, plasma-derived, pooled human immunoglobulin (IVIG) as a source of anti-AAV neutralizing antibodies to reduce peripheral transduction. Compared to controls that received naïve mouse serum, Rag1 KO mice receiving IVIG two hours prior to ICV administration of AAV-trastuzumab exhibited similar levels of trastuzumab within the brain while displaying a 10-fold reduction in serum trastuzumab concentrations. Vector biodistribution analysis suggested that reduced serum trastuzumab levels resulted from effective blockade of liver transduction following IVIG pre-treatment. These data suggest that AAV vector administration to the CNS to achieve sustained expression of trastuzumab may effectively treat Her2+ BCBM. Additionally, patients with pre-existing neutralizing antibodies to the AAV vector capsid need not be excluded from future clinical trials.
Citation Format: Marcela Salazar Werner, Shweta Aras, Ashleigh Morgan, Nesteene J. Param, Jenny Greig, James M. Wilson. Optimizing adeno-associated viral vector-mediated delivery of trastuzumab to the central nervous system for the treatment of Her2 positive brain metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB201.