EURURO-6925; No.

of Pages 3

EUROPEAN UROLOGY XXX (2016) XXX–XXX

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Platinum Priority – Brief Correspondence

Editorial by XXX on pp. x-y of this issue

Expression of AR-V7 in Circulating Tumour Cells Does Not

Preclude Response to Next Generation Androgen Deprivation
Therapy in Patients with Castration Resistant Prostate Cancer

Christof Bernemann a, Thomas J. Schnoeller b, Manuel Luedeke b, Konrad Steinestel c,

Martin Boegemann a, Andres J. Schrader a, Julie Steinestel a,*
a b c
Clinic of Urology, University Hospital Muenster, Muenster, Germany; Clinic of Urology, University Hospital Ulm, Ulm, Germany; Gerhard-Domagk-
Institute of Pathology, University Hospital Muenster, Muenster, Germany

Article info Abstract

Article history: The androgen receptor splice variant AR-V7 has recently been discussed as a predictive
Accepted July 14, 2016 biomarker for nonresponse to next-generation androgen deprivation therapy (ADT) in
patients with castration-resistant prostate cancer. However, we recently identified one
Associate Editor: patient showing a response from abiraterone despite expression of AR-V7 in his
James Catto circulating tumour cells (CTC).
Therefore, we precisely assessed the response in a cohort of 21 AR-V7 positive
castration-resistant prostate cancer patients who had received therapy with abiraterone
Keywords: or enzalutamide. We detected a subgroup of six AR-V7 positive patients showing benefit
Abiraterone from either abiraterone or enzalutamide. Their progression free survival was 26 d
Enzalutamide (censored) to 188 d. Four patients displayed a prostate-specific antigen decrease of
>50%. When analysing prior therapies, we noticed that only one of the six patients had
Androgen receptor splice variant received next-generation ADT prior to CTC collection.
AR-V7 As a result, we conclude that AR-V7 status in CTC cannot entirely predict nonresponse
Castration resistant prostate to next generation ADT and AR-V7-positive patients should not be systematically denied
cancer abiraterone or enzalutamide treatment, especially as effective alternative treatment
options are still limited.
Patient summary: A subgroup of patients can benefit from abiraterone and/or enzalu-
tamide despite detection of AR-V7 splice variants in their circulating tumour cells.
# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Department of Urology, Muenster University Medical Centre, Albert-

Schweitzer-Campus 1, Building A 1, Muenster D-48149, Germany. Tel. +49 (0) 2 51/83-44609;
Fax: +49 (0) 2 51/83-44619.
E-mail address: julie.steinestel@ukmuenster.de (J. Steinestel).

One of the major mechanisms conferring resistance to making it potentially invulnerable to next generation ADT
androgen deprivation therapy (ADT) is the expression of [1,2].
androgen receptor (AR) splice variants. The most abundant Recently, several publications showed the feasibility to
splice variant, AR-V7, encodes a constitutively active AR detect AR-V7 in circulating tumour cells (CTC) of castration-
variant, in which the ligand-binding domain is missing, resistant prostate cancer (CRPC) patients. Indeed, positivity
http://dx.doi.org/10.1016/j.eururo.2016.07.021
0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Bernemann C, et al. Expression of AR-V7 in Circulating Tumour Cells Does Not Preclude
Response to Next Generation Androgen Deprivation Therapy in Patients with Castration Resistant Prostate Cancer. Eur Urol
(2016), http://dx.doi.org/10.1016/j.eururo.2016.07.021
EURURO-6925; No. of Pages 3

2 EUROPEAN UROLOGY XXX (2016) XXX–XXX

for AR-V7 greatly predicted resistance to both abiraterone
and enzalutamide [3], but not to taxane-based chemother-
apy [4,5]. Thus, AR-V7 has recently been discussed as a
predictive biomarker for nonresponse to next-generation
ADT.
However, we recently identified one AR-V7-positive
patient, who showed response to abiraterone with a
prostate-specific antigen (PSA) decrease of more than 50%
[6]. Likewise, Antonarakis et al. [3] detected one patient
showing a PSA decrease of approximately 30% upon
enzalutamide treatment despite AR-V7 expression. In both
studies, biochemical response was defined as a PSA decline
of more than 50%. However, in clinical routine a PSA
decrease of less than 50% and even an increase of less than
25% of the PSA nadir would not argue for a therapy switch
according to current clinical prostate cancer guidelines
[7]. Thus, we hypothesized that a subgroup of patients
might benefit from next-generation ADT in terms of stable
disease despite expression of AR-V7 in CTCs.
Therefore, we retrospectively analysed AR-V7-positive
CRPC patients who had received next-generation ADT. A
CTC collection had been performed right before the start of
therapy with either abiraterone or enzalutamide. CTC
analyses were performed using immuno-magnetic bead-
based tumour cell isolation (ProstateCancer Select and
ProstateCancer Detect; Qiagen, Hannover, Germany) fol-
lowed by reverse transcription and quantitative real-time
polymerase chain reaction (see Steinestel et al. [6]). We
defined substantial benefit as either stable disease (< 50%
PSA decrease to < 25% PSA increase from PSA nadir), or
response (PSA decrease > 50%).
Six out of 21 AR-V7-positive patients experienced benefit
from next-generation ADT. Four patients even displayed a
PSA decrease of more than 50%, which is in strong contrast to
other reports describing a strict correlation between
expression of AR-V7 and resistance to next-generation
ADT [3,8]. The six AR-V7-positive patients responding to
abiraterone or enzalutamide showed a median progression-
free survival (PFS) of 2.9 mo. The median PFS for the four
patients with more than a 50% PSA decrease was 3.4 mo.
Additionally, one of these four patients had a 73% PSA
decrease and died after 26 d (0.9 mo) from a cause other than
prostate cancer. Therefore, the true median PFS might even
be higher than 2.9 mo or 3.4 mo.
However, the median PFS for AR-V7-negative patients
receiving abiraterone or enzalutamide in the cohort of
Antonarakis et al. [3] was approximately 6 mo. Thus, the
duration of response might still be longer in AR-V7-negative
patients.
Tumour and patient characteristics of the six AR-V7-
positive patients who experienced benefit from next-
generation ADT did not differ significantly from the
15 AR-V7-positive patients showing PSA progression. The
median age of benefiting patients (BP; n = 6) versus
nonbenefiting patients (NBP; n = 15) was 77 yr versus
75 yr. They had presented with an initial Gleason score 8
in 100% versus 60% of cases. BP and NBP had been stable to
first-generation ADT for a median of 12 mo and 13 mo,

Fig. 1 – Overview of prior and new therapies along with androgen receptor splice variant (AR-V7) to androgen receptor full length (AR-FL) ratio (%),
prostate-specific antigen (PSA) response (%), and progression free survival (PFS; d) for the six AR-V7-positive patients experiencing benefit from next
generation androgen deprivation therapy (ADT).

Please cite this article in press as: Bernemann C, et al. Expression of AR-V7 in Circulating Tumour Cells Does Not Preclude
Response to Next Generation Androgen Deprivation Therapy in Patients with Castration Resistant Prostate Cancer. Eur Urol
(2016), http://dx.doi.org/10.1016/j.eururo.2016.07.021
EURURO-6925; No. of Pages 3
EUROPEAN UROLOGY XXX (2016) XXX–XXX
respectively. However, the BP might have been in a slightly
earlier state in their course of disease compared with the
NBP since their PSA level at the time of blood collection and
start of next-generation ADT with either abiraterone or
enzalutamide was 119 ml (range, 30–371 ng/ml) in BP and
532 ml (range, 33–1338 ng/ml) in NBP.
Although the numbers are too low to draw conclusions,
we noted that only one of the six (16.7%) BP but nine of the
15 (60%) NBP had prior novel AR-targeted therapy (Fig. 1).
None of the four AR-V7-positive patients with more than a
50% PSA reduction had prior therapy with abiraterone or
enzalutamide. This raises the question whether the splice
variant AR-V7 might not represent the mechanism of
resistance itself, but is rather an epiphenomenon of
significant AR targeting pretreatment. In this case, an (yet
unknown) additional mechanism would underlie the
development of resistance that develops increasingly with
effective ADT.
Further, we evaluated whether the AR-V7 to AR-full
length ratio could distinguish BP from NBP but found no
correlation in our cohort (median: 7.5% vs 8.0%, respectively;
Fig. 1). This might be because CTCs represent a specialised
tumour cell population and comparison of their biological
profile with the main tumour from which they are derived is
a field of ongoing research [9,10]. While we are convinced
that the presence of AR-V7 in the CTC population proves the
existence of an AR-V7-expressing tumour, it would be rather
hypothetical to extrapolate the absolute or relative levels of
AR-V7 in these cells on the whole tumour mass. Accordingly,
a recent publication analysing CTCs on the single cell level
showed heterogeneity among the CTCs with respect to splice
variant expression even within one patient. Whereas some
cells expressed high amounts of AR-V7, other CTCs of the
same patient from the same blood sample expressed only
low levels or were negative for AR-V7 [11,12]. It is impossible
to differentiate whether only a few CTCs express high levels
of AR-V7 or if a large number of CTCs are characterised by
weak AR-V7 expression, which is a limitation of the
technique used in our study. However, we feel that our
observations are of crucial relevance for the discussion
regarding the usability of detectable AR-V7 transcripts in
CTCs as a predictive biomarker in CRPC, all the more since we
employed the identical technique used by Antonarakis et al.
[3] in their ground-breaking 2014 publication.
Our findings are of crucial clinical relevance as they
demonstrate that AR-V7 expression cannot entirely predict
nonresponse to next-generation ADT. Therefore, AR-V7-
positive patients should not be denied abiraterone or
enzalutamide treatment systematically, even more since
effective alternative treatment options are still limited.
Additional studies will have to focus on specifically
delineating the differences in benefit from abiraterone and
enzalutamide in AR-V7-positive versus -negative patients.
Author contributions: Julie Steinestel had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Please cite this article in press as: Bernemann C, et al. Expression of AR-V7 in Circulating Tumour Cells Does Not Preclude
Response to Next Generation Androgen Deprivation Therapy in Patients with Castration Resistant Prostate Cancer. Eur Urol
(2016), http://dx.doi.org/10.1016/j.eururo.2016.07.021
3
Study concept and design: Bernemann, Steinestel J.
Acquisition of data: Schnoeller.
Analysis and interpretation of data: Steinestel J, Schrader.
Drafting of the manuscript: Bernemann, Steinestel J, Steinestel K.
Critical revision of the manuscript for important intellectual content:
Schrader, Steinestel J, Steinestel K.
Statistical analysis: Luedecke, Steinestel J.
Obtaining funding: Schrader.
Administrative, technical, or material support: Boegemann.
Supervision: Steinestel J, Schrader.
Other: None.
Financial disclosures: Julie Steinestel certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: None.
Funding/Support and role of the sponsor: Anneliese Pohl Foundation
played a part in the design and conduct of the study.
References
[1] Sun S, Sprenger CC, Vessella RL, et al. Castration resistance in human
prostate cancer is conferred by a frequently occurring androgen
receptor splice variant. J Clin Invest 2010;120:2715–30.
[2] Chan SC, Li Y, Dehm SM. Androgen receptor splice variants
activate androgen receptor target genes and support aberrant
prostate cancer cell growth independent of canonical androgen
receptor nuclear localization signal. J Biol Chem 2012;287:
19736–49.
[3] Antonarakis ES, Lu C, Wang H, et al. AR-V7 and resistance to
enzalutamide and abiraterone in prostate cancer. N Engl J Med
2014;371:1028–38.
[4] Antonarakis ES, Lu C, Luber B, et al. Androgen receptor splice
variant 7 and efficacy of taxane chemotherapy in patients with
metastatic castration-resistant prostate cancer. JAMA Oncol
2015;1:582–91.
[5] Onstenk W, Sieuwerts AM, Kraan J, et al. Efficacy of cabazitaxel in
castration-resistant prostate cancer is independent of the presence
of ar-v7 in circulating tumor cells. Eur Urol 2015;68:939–45.
[6] Steinestel J, Luedeke M, Arndt A, et al. Detecting predictive andro-
gen receptor modifications in circulating prostate cancer cells.
Oncotarget. In press. http://dx.doi.org/10.18632/oncotarget.3925.
[7] Cookson MS, Lowrance WT, Murad MH, Kibel AS. American Uro-
logical Association. Castration-resistant prostate cancer: AUA
guideline amendment. J Urol 2015;193:491–9.
[8] Steinestel J, Schrader AJ, Luedeke M. Resistance to androgen-path-
way drugs in prostate cancer. N Engl J Med 2014;371:2234.
[9] Armstrong AJ, Marengo MS, Oltean S, et al. Circulating tumor cells
from patients with advanced prostate and breast cancer display
both epithelial and mesenchymal markers. Mol Cancer Res
2011;9:997–1007.
[10] Massagué J, Obenauf AC. Metastatic colonization by circulating
tumour cells. Nature 2016;529:298–306.
[11] Miyamoto DT, Zheng Y, Wittner BS, et al. RNA-Seq of single prostate
CTCs implicates noncanonical Wnt signaling in antiandrogen resis-
tance. Science 2015;349:1351–6.
[12] Watson PA, Chen YF, Balbas MD, et al. Constitutively active andro-
gen receptor splice variants expressed in castration-resistant pros-
tate cancer require full-length androgen receptor. Proc Natl Acad
Sci U S A 2010;107:16759–65.