The Prostate 60:332^337 (2004)
`
`The Use of Trastuzumabin theTreatment of Hormone
`Refractory Prostate Cancer; Phase II Trial
`
`Ali Ziada,1 Albaha Barqawi,1* L. Michael Glode,2 Marileila Varella-Garcia,2
`Frances Crighton,1 Susan Majeski,3 Mark Rosenblum,1 Madeleine Kane,4
`Lin Chen,4 and E. David Crawford1
`1UCHSC,4200 E.9th Ave.C-319, Denver,CO
`2Department of Medicine, Division of Medical Oncology,UCHSC,4200 E.9th Ave., B-188Q4, Denver,CO
`3Anschutz Cancer Pavilion, P.O.Box 6510, Mail Stop F-700,1665 n.Ursula St.Room 3200, Aurora,CO
`4Denver VA medical Center,1055 Clermont St.111F, Denver,CO
`
`PURPOSE. To investigate the efficacy and toxicity of the antibody to the HER-2/neu receptor
`1
`(trastuzumab, Herceptin
`) in the treatment of advanced hormone-refractory prostate cancer
`(HRPC).
`MATERIALS AND METHODS. Eighteen patients with HRPC were recruited for this phase II
`trial in which they received trastuzumab for 12 weeks or until disease progression or
`unacceptable toxicity was documented. HER-2 receptor overexpression was evaluated using
`immunohistochemistry (IHC) and dual-color fluorescence in-situ hybridization (FISH) assays.
`RESULTS. Trastuzumab as a single agent demonstrated little efficacy in treating HRPC. Two
`patients demonstrated stable disease based on a decrease in PSA level to less than 50% of
`baseline. No patient demonstrated a regression of radiographic bony or soft tissue metastatic
`disease. The medication was well tolerated in 16 patients (89%), and 2 patients (11%) had to be
`hospitalized for cardiac complications.
`CONCLUSIONS. Trastuzumab (Herceptin
`) as a single agent demonstrated poor efficacy in
`treating HRPC. Based on promising results in treating breast cancer with regimens using
`1
`Herceptin
`and cytotoxic agents, a similar combination approach might demonstrate better
`efficacy in treating HRPC. Prostate 60: 332–337, 2004. # 2004 Wiley-Liss, Inc.
`
`1
`
`KEY WORDS:
`
`prostate; cancer; trastuzumab; HER-2 receptor
`
`INTRODUCTION
`
`Prostate cancer is a major health problem in the
`United States and is the most frequently diagnosed
`malignancy in males [1]. Primary treatment for prostate
`cancer refractory to primary surgical and radiother-
`apeutic treatment with curative intention or for meta-
`static cancer has been luteinizing hormone-releasing
`hormone (LHRH) agonists with or without an anti-
`androgen. While this treatment approach is effective in
`controlling the cancer, these tumors ultimately fail to
`respond to androgen blockade [2]. Novel drugs
`targeting growth factor receptors have recently been
`developed that may inhibit both growth and metastatic
`potential of cancer cells [3]. HER-2/neu, which is a
`member of
`the epidermal growth factor-receptor
`
`ß 2004 Wiley-Liss, Inc.
`
`family, is thought to play a role in regulating cell
`proliferation and differentiation of cancer cells [4,5].
`
`University of Colorado Health Sciences Center, University of
`Colorado Cancer Center, Departments of Radiation Oncology,
`Medicine, and Surgery, Divisions of Urology, Medical Oncology,
`Denver, Colorado 80017.
`*Correspondence to: Albaha Barqawi, MB, FRCS, Oncology Urology
`Fellow, University of Colorado Health Sciences Center, 4200 E. 9th
`Avenue C-319, Denver, Colorado 80262.
`E-mail: al.barqawi@uchsc.edu
`Received 29 May 2003; Accepted 19 December 2003
`DOI 10.1002/pros.20065
`Published online 5 March 2004 in Wiley InterScience
`(www.interscience.wiley.com).
`
`AVENTIS EXHIBIT 2099
`Mylan v. Aventis, IPR2016-00712
`
`

`
`The Use of Trastuzumab in theTreatment of HRPC
`
`333
`
`1
`
`; Genentech, Inc., South
`Trastuzumab (Herceptin
`San Francisco, CA) has been shown to have single-
`agent activity in refractory metastatic breast cancer [6]
`but, more significantly, when trastuzumab was com-
`bined with taxane agents (i.e., paclitaxel or docetaxel),
`response rates of 38–63%, respectively, have been
`reported [7,8]. In addition, Burris et al. reported an
`overall response rate of 45% for docetaxel administered
`every 3 weeks plus weekly trastuzumab in metastatic
`breast cancer patients [9]. Studies of lung and prostate
`cancer have found conflicting results in the frequency
`of overexpression and the association of gene and
`protein levels in tumors; these findings differ from
`studies of breast cancer, in which approximately 30% of
`patients over-express the HER-2 receptor, and the
`protein overexpression is highly correlated with gene
`amplification [10]. Although the histological type of
`the tumors included in these studies may account
`for part of
`the discrepancy,
`there are additional
`correlative challenges related to technical and inter-
`pretative difficulties. At the protein level, immunohis-
`tochemistry (IHC) results may vary with the type of
`antibody selected and different criteria for definition of
`positive cases [11]. At the DNA level, Southern blot
`results may be biased by the dilution of tumor cells with
`surrounding normal cells, and the fluorescence in situ
`hybridization (FISH) assays gene amplification may be
`confounded by chromosomal polysomy [12]. Overall,
`overexpression of the HER-2 receptor is not prevalent
`in prostate cancer (4%) [13], and clustered gene
`amplification in primary prostate cancer has rarely
`been found (2%) in large-sample studies [14,15].
`However, Signoretti et al. reported that HER-2 receptor
`expression appeared to increase with progression to
`androgen independence, thereby supporting thera-
`peutic targeting of this molecule in hormone-refractory
`prostate cancer (HRPC) [16]. Moreover, investigations
`focused on prostate cancer in vitro have demonstrated
`that trastuzumab as a single agent inhibited androgen-
`dependent cell-line growth [17]. Prostate carcinoma
`being multi-focal and extremely heterogeneous, it is
`entirely likely that the initial biopsies do not represent
`the metastatic form of the disease. Due to failure to
`obtain new samples
`from all of our patients
`with metastasis especially those patients who have
`either underwent surgery to remove the prostate
`or have been on hormonal treatment for extended
`periods of time shrinking their prostate. This was the
`basis of our decision to go ahead with treating patients
`in spite of failing to prove HER-2 over-expression in
`every case.
`The current trial was conducted to determine the
`efficacy of trastuzumab as a single agent in clinical
`patients with metastatic prostate cancer who had failed
`androgen-suppression therapy and to test whether a
`
`response to treatment could correlate with gene ampli-
`fication and receptor protein levels.
`
`MATERIALS AND METHODS
`
`Patients diagnosed with prostate carcinoma were
`eligible for the study based on a demonstrated rise of
`serum prostate-specific antigen (PSA) on two consecu-
`tive biweekly draws, despite effective hormonal
`therapy and antiandrogen withdrawal for at least
`6 weeks. Patients with a history of previous chemother-
`apy or significant cardiac disease were excluded from
`the study. Eligible patients were entered into the study
`voluntarily after extensive discussion of the trial and
`informed consent as approved by the Institutional
`Review Board. All patients underwent an initial history
`including performance status evaluation, physical
`exam, laboratory and radiographic evaluation with
`chest X-ray, abdominal computerized tomography
`(CT), and a bone scan. Multiple gated acquisition
`(MUGA) scans or echocardiograms were not per-
`formed as baseline screening.
`Trastuzumab was administered at an 8 mg/kg IV
`loading dose over 90 min at week 1, with repeat doses of
`4 mg/kg weekly thereafter for 12 weeks or until disease
`progression was demonstrated by PSA, radiographic,
`or symptomatic progression.
`Patients were followed closely, with physical exam-
`inations repeated at weeks 1, 2, 4, and 12. Laboratory
`tests to monitor toxicity (i.e., CBC, electrolytes, liver
`function tests, and coagulation profile) were repeated
`at weeks 1, 4, and 12. PSA levels were drawn at the time
`of the loading dose of trastuzumab and were repeated
`at weeks 1, 4, and 12. Chest X-ray and bone scan were
`repeated at week 12. Patients were continued in the
`study until they demonstrated a continued PSA ele-
`vation (i.e., >10% rise over baseline on two consecutive
`occasions at
`least 2 weeks apart) or developed
`symptoms of metastatic disease, at which time they
`were removed from the study and offered alternative
`chemotherapy.
`The NCI common toxicity criteria [CTC v. 2.0] for
`laboratory and patient reports were used to monitor
`toxicity throughout the trial. Disease progression was
`assessed by subjective development of symptoms, PSA
`progression, or regression, and radiographic imaging
`to demonstrate progression of prior lesions or the
`development of new metastatic lesions.
`
`IHC and FISHAssays
`
`All of the specimens were obtained from initial
`biopsies and not from metastatic foci. Dual-color FISH
`assays were performed with the PathVysion probe
`(Vysis, Downers Grove, IL), including the LSI HER2
`
`

`
`334
`
`Ziada et al.
`
`sequence labeled in Spectrum Orange and the chromo-
`some 17 centromere sequence labeled in Spectrum
`Green. IHC staining with the anti-c-erb-B2 antibody
`(Ventana Medical) was performed according to the
`manufacturer’s instructions. Cellular localization and
`intensity of the stain, as well as frequency of stained
`cells, were evaluated. Protein overexpression was
`assessed as follows: no membrane or faint, partial stain-
`ing was assessed as negative; weak complete mem-
`brane staining in >10% of cancer cells was assessed as
`positive 2þ; and intense membrane staining in >10%
`of cells was assessed as positive 3þ. These cut-offs
`for over-expression were uncertain at the time of
`analysis and arbitrarily set. Another controversy with
`HER-2 was the exact
`localization of
`the staining
`(cytoplasmic versus cell membrane) obtained with
`different antibodies.
`Approximately 100 non-overlapping nuclei per site
`were scored to determine the copy number of gene and
`chromosome fluorescent signals; strict scoring guide-
`lines were followed and microscope focus was con-
`stantly adjusted since signals were located at different
`focal planes. At least 100 nuclei in 1 histologically
`normal area were analyzed per patient as a control. The
`FISH results on normal prostate cells were used to
`establish the cut-off values (mean  3 SD) for the defi-
`nition of gene and chromosome status in the tumors.
`Tested areas were defined as disomic for Her-2/neu
`and chromosome 17 when the average copy numbers
`were below the cut-off values. Sites were defined as
`displaying gene or chromosome gain when the average
`copy number of the gene and chromosome was higher
`than those expected for disomic cells. Unbalanced gene
`gain or low level of amplification was defined when the
`HER-2 gene/chromosome 17 ratio was 1.2–<2, and
`gene amplification was defined as a gene/chromosome
`ratio 2.
`
`Statistical Methods
`
`Due to the small number of patients in this study,
`statistical calculations were minimal. The null hypoth-
`esis stated that the use of HER-2 receptor antibodies has
`no effect on the clinical or the biochemical progression
`of HRPC. A primary efficacy end point was set at a
`
`TABLE I. Patient Progression Findings
`
`10% rise in serum PSA over baseline for the duration
`of the study and the absence of clinical symptoms
`indicating new metastatic disease. A further study of
`Herceptin in HPPC would be recommended if >30% of
`patients demonstrated a positive response rate while
`on the treatment. The patient accrual was discontinued
`at 18, because of the lack expression in most of them.
`With the results not very encouraging, there was
`statistical value for recruiting more patients. Also in
`light of the previous studies in breast carcinoma, it was
`thought that there was more promise in combination
`chemotherapy over trastuzumab monotherapy.
`
`RESULTS
`
`Of the 18 patients who entered the trial, 13 had bone
`metastases only, 1 had disease measurable on CT scan
`only, 3 had radiologic evidence of both bone and soft
`tissue disease, and 1 had rising PSA alone. Mean (SD)
`PSA levels at the time that patients started trastuzumab
`were 421 964 ng/ml. All patients were treated with
`trastuzumab for 4–16 weeks (mean duration 8 weeks).
`Sixteen patients (89%) had evidence of disease progres-
`sion based on PSA results between 3 and 12 weeks of
`treatment, and 2 patients had evidence of stable disease
`based on serial PSA values (<10% rise over baseline on
`two consecutive occasions at least 2 weeks apart). One
`patient had a PSA of 106.2 ng/ml at baseline, 79.4 ng/
`ml at week 3, 56 ng/ml at week 7, and 68.2 ng/ml at
`week 12. In the second patient with evidence of stable
`disease, the PSA level was 459.6 ng/ml at baseline,
`407.6 ng/ml at week 3, and 422 ng/ml at week 7
`(Table I). Baseline and follow-up changes in perfor-
`mance status are shown in Table II.
`In the 18 patients, a total of 41 tumor areas (1–4 per
`patient) with histological pattern of adenocarcinoma
`were analyzed in sequential slides by IHC and dual-
`color FISH assays. Gleason score was assessed in the
`haematoxylin and eosin (H&E)-stained slide. While the
`majority showed none or weak staining on IHC assays
`and were classified as negative (Table III), tumors from
`two patients (9.5%) overexpressed HER-2 (2þ by IHC).
`In the FISH assays,
`three patients (17%) showed
`unbalanced gene gain, classified as low level of
`amplification (ratio gene/chromosome 1.2–1.6), and
`
`New CAT findingsa New bone metastasesa
`
`% PSA change
`Progression
`
`—
`3/18
`
`—
`2/18
`
`Week 3
`mean SD
`60 ( 105% (n¼ 18)
`—
`
`Week 7
`mean SD
`42 ( 73% (n¼ 9)
`—
`
`Week 12
`mean SD
`48 ( 68% (n¼5)
`—
`
`CAT, computerized axial tomography; PSA, prostate-specific antigen.
`aNo patient had any evidence of regression of metastatic lesions compared to baseline based on CAT and bone scan.
`
`

`
`The Use of Trastuzumab in theTreatment of HRPC
`
`335
`
`TABLE II. Performance Status
`
`TABLE IV. Toxicities
`
`Number of
`patients
`
`Score 0
`
`Score 1 Score 2 Score 3 Score 4
`
`Toxicity
`
`%
`Patients
`
`At baseline
`At follow-up
`
`12
`11
`
`5
`6
`
`1
`0
`
`0
`0
`
`0
`1
`
`No patient was discontinued from the study due to decline in
`performance status.
`
`two of these patients were negative for protein over-
`expression. A normal disomy pattern for both HER-2/n
`gene and chromosome 17 was found in seven (39%)
`patients, whereas balanced aneusomy (i.e., increase in
`copy numbers for both gene and chromosome) was
`found in eight patients (44%). Higher levels of protein
`expression correlated weakly (r¼ 0.44) with abnormal
`FISH patterns (i.e., balanced and unbalanced aneus-
`omy) and higher Gleason score (r¼ 0.42). Abnormal
`FISH patterns also demonstrated weak correlation with
`higher Gleason scores (r¼ 0.36).
`
`Toxicity
`
`Two patients had cardiac toxicities. The first patient
`was a 61-year-old man who developed grade 3 con-
`gestive heart failure likely related to the trastuzumab.
`He expressed symptoms of shortness of breath after
`six doses of trastuzumab and was admitted to the
`hospital. He had an elevated troponin level but
`myocardial infarction was ruled out, and symptoms
`resolved with hospitalization and routine treatment.
`He had no prior cardiac risk factors, and his pre-
`treatment EKG and MUGA were negative, i.e., they
`demonstrated normal cardiac ejection fraction. The
`second patient, who had a prior history of cardiac
`disease, developed new onset left ventricular systolic
`dysfunction and was hospitalized 25 months later with
`atrial fibrillation, which was reported as possibly
`treatment related. Overall, six patients (33%) experi-
`
`TABLE III. The Results of HER-2 Staining and FISHData
`
`Parameter
`
`Number of tumors
`
`HER-2 protein expression
`Negative
`Positive (2þ)
`HER-2 gene status per cell
`Balanced disomy
`Balanced aneusomy
`Low gene amplification
`
`16
`2
`
`7
`8
`3
`
`FISH, fluorescence in-situ hybridization.
`
`%
`
`89
`11
`
`39
`44
`17
`
`Toxicity
`
`Leukopenia
`Pain
`Atrial Fib.
`Heart block
`Ascites
`Dry skin
`Fever
`Blurred vision
`Asthenia
`Myalgia
`Elevated LFT
`Thrombocytopenia
`
`%
`Patients
`
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`5.5
`
`Fatigue
`Nausea
`Dizziness
`Syncope
`Dyspnea
`Edema
`Chest pain
`Palpitations
`Anorexia
`Renal (high Cr)
`Rigors
`Neutropenia
`
`22
`22
`11
`11
`11
`11
`11
`5.5
`5.5
`5.5
`5.5
`5.5
`
`LFT, liver function test(s).
`
`enced no toxicity, five patients (27%) experienced
`grade 1 toxicity only, two patients (11%) experienc-
`ed grade 3 toxicity, and three patients (17%) experi-
`enced grade 4 toxicity as their worst toxicity (CRC,
`version 2.0). The grade 2–4 toxicities are shown in
`Table IV.
`
`DISCUSSION
`
`In vitro studies using antibodies to the HER-2
`receptor have demonstrated retardation of cell growth
`and change in expression of the HER-2 oncogene
`[19,20]. Specific antibodies to the extracellular domain
`of the membrane-based protein product of the HER-2
`oncogene inhibit the growth of tumors that overexpress
`the gene. The exposure of HER-2 oncogene-trans-
`formed mouse fibroblast cells (NIH 3T3) to monoclonal
`antibodies reactive to the HER-2 oncogene product
`p185 produced a rapid and reversible loss of both cell-
`surface and total cellular p185 [21]. The antibody
`treatment caused the transformed NIH 3T3 cells to
`revert to a non-transformed phenotype. Furthermore,
`investigators were later able to show that monoclonal
`antibodies reactive with the oncogene-encoded protein
`directly inhibited both in vitro and in vivo tumor
`growth [22,23]. The data are consistent with a direct role
`for HER-2/neu oncogene in both malignant transfor-
`mation and augmented tumorigenicity.
`Although a weekly dose of 2–4 mg/kg had been
`shown to be a safe range for administration at the time
`of this study, the maximum weekly dose of 4 mg/kg
`was chosen in this study to demonstrate if a higher dose
`might affect the outcome in patients with poor or no
`overexpression of the HER-2 receptor. Nonetheless, in
`2002, Vogel et al. found no apparent increase in efficacy
`in metastatic breast cancer between the 2- and 4-mg/kg
`trastuzumab regimens [18].
`
`

`
`336
`
`Ziada et al.
`
`1
`
`) showed
`In this study, trastuzumab (Herceptin
`little clinical efficacy in decreasing metastatic prostate
`cancer disease progression. Several possibilities may
`explain why the patients in this study did not respond
`to trastuzumab as a single agent for treating metastatic
`prostate cancer. The first possibility is related to the
`status of the gene and the level of protein expression.
`This study detected a low frequency of patients with
`protein overexpression (9.5%) or a low level of HER-2
`amplification by interphase FISH (17%). These results
`are concordant with the majority of recent publications
`[13–15]; a clinical response of the prostate cancer to the
`trastuzumab would not be expected if the cells did not
`express the HER-2 gene product. HER-2 gene amplifi-
`cation leads to HER-2 receptor protein overexpression
`in vitro in 45% of prostate cancers [24]. However, most
`patients (52%) displayed balanced (i.e., gene¼ chromo-
`chromosome) or unbalanced (i.e., gene > chromosome)
`aneusomy, and these abnormal patterns correlated
`with higher levels of protein expression. Therefore, the
`biological significance of HER-2 gains due to extensive
`chromosome 17 aneusomy remains an interesting
`issue to be addressed. Moreover, all of our specimens
`were obtained at the initial biopsies, presumably prior
`to conversion to hormonal resistance, which may have
`impacted the low HER-2 overexpression rate observed
`by FISH in our study.
`The second issue is whether trastuzumab as a single
`agent would be expected to be effective in patients with
`androgen-dependent prostate cancers. Furthermore,
`trastuzumab demonstrated inhibition of prostate can-
`cer cell growth in androgen-independent cell lines
`when used in combination with paclitaxel [25]. The
`patients in this study all had androgen-independent
`prostate cancer, which may respond better to a com-
`bination of trastuzumab and a cytotoxic agent in future
`trials.
`
`CONCLUSION
`1
`
`Trastuzumab (Herceptin
`) as a single agent demon-
`strated poor efficacy in treating HRPC. Future clinical
`research using trastuzumab to treat prostate cancer,
`either as a single agent or in combination with a
`chemotherapeutic agent, may involve using combina-
`tion regimens with taxanes and directing this therapy,
`in combination with standard hormonal
`therapy,
`toward hormone-sensitive prostate cancer. An inter-
`esting question that was not answered by this trial is the
`activity of trastuzumab in patients with HRPC who
`strongly overexpress (i.e., þ3 by IHC and/or signifi-
`cant amplification of ERBB2) HER-2. Further large trials
`investigating the role of trastuzumab in treating HRPC
`should be restricted to patients with tumors strongly
`over-expressing HER-2.
`
`ACKNOWLEDGMENTS
`
`We acknowledge the excellent and substantial
`contribution to this study by the late Gary Miller
`M.D., who helped with his expertise in reading the IHC
`and FISH samples and the overall drafting of this
`manuscript.
`
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