Primary Mutational Landscape Linked with Pre-docetaxel Lactate Dehydrogenase Levels Predicts Docetaxel Response in Metastatic Castrate-resistant Prostate Cancer

Background Docetaxel chemotherapy is a standard of care for metastatic castrate-resistant prostate cancer (mCRPC): 40–50% of patients achieve a biochemical response. However, there is a lack of response predictive biomarkers. Objective To assess lactate dehydrogenase (LDH) as a docetaxel response biomarker in mCRPC and to examine the association of LDH with genomic alterations in primary diagnostic biopsies. Design, setting, and participants Clinical and associated primary tumour-targeted next-generation sequencing data from matched training (n = 150) and test (n = 120) cohorts of progressive mCRPC patients receiving docetaxel therapy were analysed. Data were correlated with large-scale prostate cancer genomic datasets. Outcome measurements and statistical analysis Prostate-specific antigen (PSA) response, radiographic response, biochemical progression-free survival (PFS), overall survival (OS), genomic analysis of primary biopsies, and genomic datasets (Memorial Sloan Kettering Cancer Center [MSKCC] and SU2C/PCF). Results and limitations Serum LDH ≥450 U/l is a reliable prognostic biomarker (area under the curve: 0.757 [standard deviation 0.054, 95% confidence interval [CI] 0.650–0.864, p < 0.001]) in progressive mCRPC, predicting PFS at 3 mo. Patients with LDH ≥450 U/l were poorer PSA responders, with shorter PFS (213 vs 372 d, hazard ratio [HR] 1.876, 95% CI 1.289–2.7300) and OS (362 vs 563 d, HR 1.630, 95% CI 1.127–2.357). High LDH is an independent surrogate marker for survival following docetaxel and predicts a poor radiological response (p = 0.043). Of the 14 patients with LDH ≥450 U/l available for next-generation sequencing, nine (64.3%) were more likely to have DNA repair gene mutation(s) (BRCA1/2, ATM, CHEK2, Fanconi anaemia gene) in their primary biopsy. Cross correlation with MSKCC and SU2C/PCF databases revealed a positive correlation between LDHA, PARP1 (r = 0.667, p < 0.01), and other DNA repair genes. Conclusions Genomic abnormalities of LDHA and DNA repair in primary biopsies link to high pretreatment LDH and poor response to docetaxel in mCRPC. Patient summary The presence of mutations of the lactate dehydrogenase and DNA repair pathways are associated with aggressive prostate cancer and poor response to chemotherapy later in the disease.