Synergistic Antitumor Efficacy Of Radium-223 In Combination With Enzalutamide In The Intratibial Lncap Prostate Cancer Xenograft Model.

Abstract Radium-223 dichloride (Ra-223) is a targeted alpha therapy that binds to newly formed bone matrix in bone metastases and induces DNA double-strand breaks in cancer cells, osteoblasts and osteoclasts. It is used for treating men with castration-resistant prostate cancer (CRPC) and bone metastases. Enzalutamide is a second-generation androgen receptor inhibitor also used for treating the same patient population, and the combination of Ra-223 and enzalutamide is currently being investigated in clinical trials. We evaluated the antitumor efficacy of Ra-223 and enzalutamide in the LNCaP intratibial model mimicking prostate cancer metastasized to bone. LNCaP prostate cancer cells were inoculated into the right tibia of male NOD.scid mice. The mice were randomized (n=9/group) based on serum PSA and treated with vehicle, Ra-223 (330 kBq/kg, i.v., Q4W x 2), enzalutamide (30 mg/kg, p.o., QD) or with a combination treatment of Ra-223 and enzalutamide, for 28 days. Serum PSA levels were analyzed at the end of the study and compared to the pre-treatment levels. Serum bone formation and resorption biomarkers, PINP and CTX, respectively, were measured during the study. Tumor-induced abnormal bone area, Ra-223 uptake and bone formation were determined by X-ray, gamma counter and histomorphometry, respectively. The healthy tibiae were evaluated by microCT. Combination treatment showed synergistic antitumor efficacy as observed by lower PSA levels when compared to the vehicle, Ra-223 or enzalutamide monotherapies (p=0.04, p=0.008 and p=0.002, respectively). A statistical interaction between Ra-223 and enzalutamide treatments was found (p=0.003), confirming the synergistic effect. In combination treatment, the serum PSA change relative to pre-treatment levels was 18% of the vehicle. Accordingly, a decreasing trend (p=0.08) in tumor-induced abnormal bone changes was associated with the combination treatment in the tumor-bearing tibiae (46% of the vehicle), whereas no changes in total bone structure were observed in the healthy tibiae. The serum levels of PINP and CTX were lowest in mice treated with the combination treatment. Compared to Ra-223 monotherapy, concurrent administration of enzalutamide with Ra-223 did not affect either Ra-223 uptake or bone formation rate in tumor-bearing or healthy tibiae, respectively. Compared to Ra-223 and enzalutamide monotherapies, the combination treatment demonstrated synergistic antitumor efficacy by decreasing PSA levels in the LNCaP intratibial model. Despite of prominent effects on tumor growth, the combination treatment was not observed to compromise bone health in the healthy tibiae. In conclusion, these preclinical results support the ongoing phase 3 trials PEACE III (NCT02194842) & ESCALATE (NCT04237584) of this combination. Citation Format: Mari I. Suominen, Matias Knuuttila, Jukka Vääräniemi, Birgitta Sjöholm, Esa Alhoniemi, Dominik Mumberg, Sanna-Maria Käkönen, Arne Scholz. Synergistic antitumor efficacy of radium-223 in combination with enzalutamide in the intratibial LNCaP prostate cancer xenograft model [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 1392.