Prostate-specific Membrane Antigen Heterogeneity and DNA Repair Defects in Prostate Cancer

Abstract Background Prostate-specific membrane antigen (PSMA; folate hydrolase) prostate cancer (PC) expression has theranostic utility. Objective To elucidate PC PSMA expression and associate this with defective DNA damage repair (DDR). Design, setting, and participants Membranous PSMA (mPSMA) expression was scored immunohistochemically from metastatic castration-resistant PC (mCRPC) and matching, same-patient, diagnostic biopsies, and correlated with next-generation sequencing (NGS) and clinical outcome data. Outcome measurements and statistical analysis Expression of mPSMA was quantitated by modified H-score. Patient DNA was tested by NGS. Gene expression and activity scores were determined from mCRPC transcriptomes. Statistical correlations utilised Wilcoxon signed rank tests, survival was estimated by Kaplan-Meier test, and sample heterogeneity was quantified by Shannon's diversity index. Results and limitations Expression of mPSMA at diagnosis was associated with higher Gleason grade ( p  = 0.04) and worse overall survival ( p  = 0.006). Overall, mPSMA expression levels increased at mCRPC (median H-score [interquartile range]: castration-sensitive prostate cancer [CSPC] 17.5 [0.0–60.0] vs mCRPC 55.0 [2.8–117.5]). Surprisingly, 42% ( n  = 16) of CSPC and 27% ( n  = 16) of mCRPC tissues sampled had no detectable mPSMA (H-score p  = 0.016; 87.5 [25.0–247.5] vs 20 [0.3–98.8]; difference in medians 60 [5.0–95.0]); validation cohort studies confirmed higher mPSMA expression in patients with deleterious aberrations in BRCA2 ( p ATM ( p  = 0.005; 212.5 [136.3–300]; difference in medians 140.0 [55.0–200]) than in molecularly unselected mCRPC biopsies (55.0 [2.75–117.5]). Validation studies using mCRPC transcriptomes corroborated these findings, also indicating that SOX2 high tumours have low PSMA expression. Conclusions Membranous PSMA expression is upregulated in some but not all PCs, with mPSMA expression demonstrating marked inter- and intrapatient heterogeneity. DDR aberrations are associated with higher mPSMA expression and merit further evaluation as predictive biomarkers of response for PSMA-targeted therapies in larger, prospective cohorts. Patient summary Through analysis of prostate cancer samples, we report that the presence of prostate-specific membrane antigen (PSMA) is extremely variable both within one patient and between different patients. This may limit the usefulness of PSMA scans and PSMA-targeted therapies. We show for the first time that prostate cancers with defective DNA repair produce more PSMA and so may respond better to PSMA-targeting treatments.