Metabolomic diagnosis of prostate cancer

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1 Metabolomic diagnosis of prostate cancer Dr. Iulia Andraș 2 nd Urology Forum, th May 2015, Athens

2 Current screening and diagnosis PSA, fpsa, PSAV, PSADT DRE Biopsy Prediction tools MRI

Current screening and diagnosis PSA o Low Sp o No cut- off exclusion of PCa diagnosis o Screening modest reduction in mortality PSA (ng/ml) PPV 0-1 2,8-5%

3 Current screening and diagnosis PSA o Low Sp o No cut- off exclusion of PCa diagnosis o Screening modest reduction in mortality PSA (ng/ml) PPV 0-1 2,8-5% 1-2,5 10,5-14% 2, % % >10 69% Barry MJ. Screening for prostate cancer the controversy that refuses to die. New Engl J Med. 2009; 360:

4 Current screening and diagnosis Ultrasound- guided prostate biopsy o > 60-70% of initial biopsies = negative 20% false negative o 20-30% confirmation rate for the 2 nd US- guided prostate biopsy o 45% of diagnosed PCa = low- risk Schroder FH, Carter HB, Wolters T et al. Early detection of prostate cancer in Part 1: PSA and PSA kinetics.eur Urol 2008; 53: Panel NGR. NCCN Clinical Practice Guidelines in Oncology Prostate Cancer Treatment.2012; version 3.0 Engehausen DG, Engelhard K, Schwab SA, Uder M, Wach S, Wullich B. Magnetic Resonance Image- Guided Biopsies with a High Detection Rate of Prostate Cancer.ScientificWorldJournal. 2012;2012:975971

5 Current screening and diagnosis Prediction tools o significant variability - low/high end of the risk spectrum o at least 30 50% of men assessed as very low risk under AS will require treatment o among high risk men with Gleason 8 10 tumors, 15 year PCa mortality may be lower than 40% Tosoian JJ, Trock BJ, Landis P, et al. Active surveillance program for prostate cancer: an update of the Johns Hopkins Experience. J Clin Oncol. 2011; 29: Eggener SE, Scardino PT, Walsh PC, et al. Predicting 15- year prostate cancer specific mortality after radical prostatectomy. J Urol. 2011; 185:

6 Current screening and diagnosis mpmri o PZ PCa T2WI+DWI+DCE- MRI => Se 83% T2WI+DWI+DCE- MRI + spectroscopy => Se 86% Sp 100% o PZ+TZ PCa T2WI+DCE- MRI+spectroscopy => Se 73% Sp 89% Tamada T, Sone T, Higashi H, Jo Y, Yamamoto A, Kanki A, et al. Prostate cancer detection in patients with total serum prostate- specific antigen levels of 4-10 ng/ml: diagnostic efficacy of diffusion- weighted imaging, dynamic contrastenhanced MRI, and T2- weighted imaging. AJR Am J Roentgenol 2011;197:664e70 Turkbey B, Mani H, Shah V, Rastinehad AR, Bernardo M,Pohida T, et al. Multiparametric 3T prostate magnetic resonance imaging to detect cancer: histopathological correlation using prostatectomy specimens processed in customizedmagnetic resonance imaging based molds. J Urol 2011;186:1818e24 Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y,McKinney YL, et al. Prostate cancer: value of multiparametric MR imaging at 3.0 T for detectiondhistopathologic correlation. Radiology 2010;255:89e99

7 Current screening and diagnosis mpmri o PZ PCa HIGH VOLUME CENTERS 3T MRI T2WI+DWI+DCE- MRI => Se 83% T2WI+DWI+DCE- MRI + spectroscopy => Se 86% Sp 100% o PZ+TZ PCa T2WI+DCE- MRI+spectroscopy => Se 73% Sp 89% Tamada T, Sone T, Higashi H, Jo Y, Yamamoto A, Kanki A, et al. Prostate cancer detection in patients with total serum prostate- specific antigen levels of 4-10 ng/ml: diagnostic efficacy of diffusion- weighted imaging, dynamic contrastenhanced MRI, and T2- weighted imaging. AJR Am J Roentgenol 2011;197:664e70 Turkbey B, Mani H, Shah V, Rastinehad AR, Bernardo M,Pohida T, et al. Multiparametric 3T prostate magnetic resonance imaging to detect cancer: histopathological correlation using prostatectomy specimens processed in customizedmagnetic resonance imaging based molds. J Urol 2011;186:1818e24 Turkbey B, Pinto PA, Mani H, Bernardo M, Pang Y,McKinney YL, et al. Prostate cancer: value of multiparametric MR imaging at 3.0 T for detectiondhistopathologic correlation. Radiology 2010;255:89e99

8 Current screening and diagnosis Increased screening + early detection of indolent PCa => large disparity: incidence vs lethality Overdiagnosis/overtreatment

9 Current screening and diagnosis Screening 781 pts Treat 27 pts Avoid one death due to PCa

Current screening and diagnosis need for new biomarkers o beoer screening strategies o indolent vs aggressive ultimate goal of current research: o to minimize false

10 Current screening and diagnosis need for new biomarkers o beoer screening strategies o indolent vs aggressive ultimate goal of current research: o to minimize false positives o to treat only those men who are at the greatest risk for aggressive forms of PCa o to reduce testing and treatment for those at low risk for the disease

11 New biomarkers

12 Metabolomics?!

13 New biomarkers Metabolomics = evaluation of the paoerns and concentration of low molecular weight metabolites over broad classes of compounds in a tissue or organ intermediate and end products of the intracellular biochemical reactions mass typically in the range of Daltons

14 New biomarkers the known metabolome - smaller than the number of genes, transcripts, or proteins downstream of changes in genes and proteins => metabolomics may more clearly characterize altered cellular networks metabolic alterations occur early - > targets for intervention Blood, urine and tissue

15 Advantages?

16 New biomarkers several circulating glycerophospholipid, faoy acid, energy and related metabolites - inversely associated with aggressive prostate cancer up to 20 years prior to diagnosis

17 Characteristics of prostatic tissue Normal prostate/ BPH Significance - High levels of zinc in prostatic fluid ( times that in blood) - inhibit the mitochondrial (m- ) aconitase activity - Seminal fluid high concentration of citrate ( nmol/g of tissue) - Due to the inhibition of m- aconitase, which converts citrate to isocitrate in the TCA cycle Costello LC, Franklin RB. Concepts of citrate production and secretion by prostate. 1. Metabolic relationships. Prostate. 1991; 18(1):25 46 Franklin, RB.; Costello, LC. Intermediary energy metabolism of normal and malignant prostate epithelial cells. In: Naz, RK., editor. Prostate: Basic and Clinical aspects. New York: CRC Press; p Costello LC, Franklin RB. The intermediary metabolism of the prostate: a key to understanding the pathogenesis and progression of prostate malignancy. Oncology. 2000; 59(4): Costello LC, Franklin RB, Feng P. Mitochondrial function, zinc, and intermediary metabolism relationships in normal prostate and prostate cancer. Mitochondrion. 2005; 5(3):

18 Characteristics of prostatic tissue Malignant prostate Significance - citrate levels decrease to nmol/g - malignant prostate cells oxidize citrate in the TCA cycle - low levels of zinc - decreased expression of zinc transporters - spermine, phosphocholine and total choline- containing compounds are increased - increased demand for lipid synthesis - increased uptake of choline - increased expression of choline transporters Kolenko V, Teper E, Kutikov A, Uzzo R. Zinc and zinc transporters in prostate carcinogenesis. Nat Rev Urol. 2013; 10(4): Lynch MJ, Nicholson JK. Proton MRS of human prostatic fluid: correlations between citrate, spermine, and myo- inositol levels and changes with disease. Prostate. 1997; 30(4): Glunde K, Jacobs MA, Bhujwalla ZM. Choline metabolism in cancer: implications for diagnosis and therapy. Expert Rev Mol Diagn. 2006; 6(6):

19 Prostate metabolome Lipids o Inositol- 1- phosphate o Glycerol- 3- phosphate Amino- acids o Leucine o Proline o Sarcosine Xenobiotics Nucleotides o Uracil Peptides Energy molecules o Citrate

20 Methods in metabolomic profiling Mass spectrometry o Gas cromatography o Liquid cromatography Nuclear magnetic resonance spectroscopy Magnetic resonance spectroscopic imaging

21 Disadvantages?

24 Biases variability in the physiological and pathological state of the samples specimen collection procedure size and selection of the study cohorts methodologic differences lack of standardization

25 Our experience

26 Our experience Total 134 patients o 85 before biopsy (39 BPH, 46 PCa) o 37 confirmed PCa, before RP o 12 controls LC- QTOF- (ESI+)- MS - Bruker Daltonics MaXis Impact Aminoacid Metabolomics Lipidomics

27 Our experience Seric aminoacid quantitative analysis lysine phenylalanine alanine glycine Putluri et al, 2011 Teahan et al, 2011 Kami et al, 2013 PCa vs BPH and control (p<0.05) arginine PCa vs BPH and control (p<0.05) Vissers et al, 2005

28 Our experience Urine aminoacid quantitative analysis glutamine alanine leucine PCa vs BPH hystidine phenylalanine tryptophane tyrosin PCa vs BPH

29 Conclusion No single metabolite, BUT the metabolic flux of metabolites in a particular pathway may be more useful for screening and prediction of PCa aggressiveness

30 Conclusion No single metabolite, BUT the metabolic flux of metabolites in a particular pathway may be more useful for screening and prediction of PCa aggressiveness FUTURE PCa fluxomics Pharmacometabolomics Personalised medicine

31 Thank you!

32 Mass spectrometry Sreekumar et al, metabolites (52 significant) o Diff benign vs localized PCa vs metastatic PCa o Sarcosine McDunn et al, 2013 o glycerol- 3- phosphate, sarcosine,kynurenine, proline, threonine, and uracil - mpca o sarcosine levels - elevated only in tissue biopsies with a Gleason paoern of 8 or worse McDunn JE, Li Z, Adam KP, Neri BP, Wolfert RL, Milburn MV, Lotan Y, Wheeler TM. Metabolomic signatures of aggressive prostate cancer. Prostate. 2013; 73(14): Sreekumar A, Poisson LM, Rajendiran TM, Khan AP, Cao Q, Yu J et al. Metabolomic profiles delineate potential role for sarcosine in prostate cancer progression. Nature. 2009; 457(7231):

33 New biomarkers Prostate health index TMPRSS2- ERG gene fusion α- methyl- coenzyme A racemase (AMACR) circulating tumor cells (CTCs) in the blood stream prostate derived exosomes PCA3 o most promising o non- invasive o detected in urine of patients with metastatic disease o can be used in conjunction with the PSA test for prostate cancer screening 15,16,17 REFERINTEEEEE

34 Mass spectrometry initial separation of metabolites by GC or LC, followed by ionization of metabolites and resolution according to mass- to- charge ratio advantage high Se and detection of metabolites at very low concentrations extensive sample preparation (particularly for GC- MS), and metabolite detection can be complicated by differences in ionization efficiency, stability, extraction efficiency, and fragmentation behavior

Nuclear magnetic resonance spectroscopy exploits the behaviour of molecules when placed in a magnetic field, allowing the identification of different nuclei based on their resonant frequency for a

35 Nuclear magnetic resonance spectroscopy exploits the behaviour of molecules when placed in a magnetic field, allowing the identification of different nuclei based on their resonant frequency for a mixture of metabolites in a biological sample the different paoerns of energy release are represented as peaks in a chromatogram, and the area of the peaks is indicative of the relative concentration of each type of metabolite liquids or tissue extracts advantages: low cost, minimal sample preparation requirements, high reproducibility, ability to quantify metabolites, and identification of unknown metabolites

36 Magnetic resonance spectroscopic imaging elevated choline + reduced citrate Kurhanewicz J, Vigneron DB. Advances in MR spectroscopy of the prostate. Magn Reson Imaging Clin N Am. 2008; 16(4):

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